The state legislature has opened the door for employers in Illinois to develop their own workers’ compensation PPO, titled a Preferred Provider Panel (PPP). Oversight of the PPP was appointed to the Department of Insurance (DOI), which is working diligently to comply and assist employers and insurance professionals as they navigate the PPP concept and practice.
As I write this column, no employer or insurance carrier has an approved PPP. However, some statewide networks have applied for PPP approval from the DOI by submitting their existing networks for approval under the new law.
Here are answers to some of the frequently asked questions regarding the PPP concept.
Does an employer have to join a PPP? No. If an employer is satisfied with its process and provider, it does not have to do anything. Under the amended law, current processes are acceptable.
What are the benefits of joining a PPP? A PPP limits the number of provider choices an employee has (presumably providers adept at WC care, but the logistics of this assurance are sketchy right now). The employer must offer the employee an opt-out in writing at the time of injury. If the employee opts out, he or she has only one option of provider outside the PPP (and all subsequent referrals from that provider) instead of the two options within the PPP.
Does a PPP allow me to direct care to a primary care physician who serves as a gatekeeper, like an HMO? Not at this time. An employer lists PPP providers, and the employee chooses from among those listed. Once the employer has chosen a PPP, it is bound by those listed choices. The employer may not direct inside or outside the network. A physician may utilize a non-network provider if the required care is not available within the PPP. Practically speaking, the PPP can not only limit the employee’s choice, but also the employer’s input.
Are these PPPs specific to my geographic area? Unless the PPP is region-specific (or a sub-network nested within a larger network), the employee chooses any network provider regardless of geographic location, and the PPP geographic limitations must be based upon the employee’s residence, not the employer location. If the PPP is statewide and has providers in Peoria, Carbondale and Chicago, the employee may choose to see any of them.
Can an employer develop his or her own PPP? Yes. However, it is not simply a matter of writing down a few providers’ names. The PPP must be compliant with Section 2051 of the Insurance Code, which is not yet amended with all the new language regulating the workers’ compensation statute.
Are medical providers required to join PPPs or register with the state to provide workers compensation care? No. There are no requirements for medical providers to join any network or register with the state to be eligible to treat workers’ compensation claims.
Our analysis is that in the current form, PPPs have unanswered questions that could leave employers with no more control over the workers’ compensation process than they have now. Once honed (which will take some time), they could offer some employers a valuable tool for workers’ compensation management, but they have not yet been vetted or developed to a point of usefulness for most. In short, be patient. iBi
