Common use of Medical Provider Clause in Contracts

Medical Provider. A. This Agreement does not constitute a Medical Provider Network (“MPN”). Physicians who act as a covered employee’s independent medical examiner (“IME”) under this Agreement shall not act as the same employee’s treating physician even if the physician has been pre-designated as the employee’s treating physician, unless otherwise mutually agreed by the parties. Pre-designation of a physician must comply with the requirements set forth in Labor Code section 4600(d)(1). B. All employees with a disputed medical issue as described below in Section D must be evaluated by an approved physician from the exclusive list of approved medical providers. Said physician will serve as an IME. If the IME needs the opinion of a different specialist, the IME shall refer the employee to a physician of the IME’s choice even if that doctor is not on the approved list. The exclusive list of approved medical providers will be established when the Agreement has been approved by all parties. C. The exclusive lists of approved medical providers shall include the specialties as agreed upon by the parties. D. An IME shall be used for all medical disputes that arise in connection with a workers’ compensation claim including but not limited to determination of causation, the nature and extent of an injury, the nature and extent of permanent disability and apportionment, work restrictions, ability to return to work, including transitional duty, future medical care, and resolution of all disputes arising from utilization review, including need for spinal surgery pursuant to Labor Code section 4062(b). The parties will use the originally chosen IME for all subsequent disputes under this Agreement. In the event that said IME is no longer available, then the parties shall utilize the next specialist on the list pursuant to Article IV G d (below). The IME process will begin when either party gives the other written notice of an objection. Objections from the City will be sent to the employee with a copy to the employee’s legal representative if represented and a copy to FMA. Objections from the employee or employee’s legal representative will be sent to the employee’s assigned Claims Examiner with a copy to the Claims Manager. Objections will be sent within thirty days of receipt of a medical report or a utilization review decision. A letter delaying decision of the claim automatically creates a dispute. A subsequent acceptance of the claim and/or resolution of the dispute issue eliminates the need for completion of the dispute resolution process set forth in this Agreement. E. The exclusive list of approved medical providers shall serve as the exclusive source of medical-legal evaluations as well as all other disputed medical issues arising from a claimed injury. F. The parties hereby agree that from time to time the exclusive list of approved medical providers may be amended. For either party to add an IME to the exclusive list of medical providers, the party must provide notice, in writing, to the other party of its intent to add a physician to the list. Absent a written objection to the other party within thirty (30) calendar days of receipt of the written proposal, the addition will be made. In the event there is an objection, the physician will not be added to the list. A physician may only be deleted from the exclusive list of medical providers if they breach the terms and conditions of the contract with the City or by mutual agreement of the parties.

Medical Provider. A. This Agreement does not constitute a Medical Provider Network (“MPN”). However, all employees must utilize the City’s current MPN for treatment purposes during the time the City maintains and utilizes the MPN. The MPN is governed by Labor Code section 4616 et seq. Physicians who act as a covered employee’s independent medical examiner (“IME”) under this Agreement shall not act as the same employee’s treating physician even if the physician has been pre-designated (pre)designated as the employee’s treating physician, unless otherwise mutually agreed by the parties. Pre-designation Predesignation of a physician must comply with the requirements set forth in Labor Code section 4600(d)(1). B. All employees with a disputed medical issue as described below in Section D must be evaluated by an approved physician from the exclusive list of approved medical providers. Said physician will serve as an IME. Attached hereto as Exhibit A is an exclusive list of approved medical providers that was agreed upon by the City and the LBFFA. If the IME needs the opinion of a different specialist, the IME shall refer the employee to a physician of the IME’s choice even if that doctor is not on the approved list. The exclusive list of approved medical providers will be established when or in the Agreement has been approved by all partiesMPN. C. The exclusive lists list of approved medical providers shall include the specialties as agreed upon by the parties. D. An IME shall be used for all medical disputes that arise in connection with a workers’ compensation claim including but not limited to determination of causation, the nature and extent of an injury, the nature and extent of permanent disability and apportionment, work restrictions, ability to return to work, including transitional duty, future medical care, and resolution of all disputes arising from utilization review, including need for spinal surgery pursuant to Labor Code section 4062(b). The parties will use the originally chosen IME for all subsequent disputes under this Agreementagreement. In the event that said IME is no longer available, then the parties shall utilize the next specialist on the list pursuant to Article IV G d 5 (below). The IME process will begin be triggered when either party gives the other written notice of an objection. Objections from the City will be sent to the employee with a copy to the employee’s legal representative if represented and a copy to FMALBFFA. Objections from the employee or employee’s legal representative will be sent to the employee’s assigned Claims Examiner claims examiner with a copy to the Claims Manager. Objections will be sent within thirty days of receipt of a medical report or a utilization review decision. A letter delaying decision of the claim automatically creates a dispute. A subsequent acceptance of the claim and/or resolution of the dispute issue eliminates the need for completion of the dispute resolution process set forth in this Agreementagreement. E. The exclusive list of approved medical providers shall serve as the exclusive source of medical-legal evaluations as well as all other disputed medical issues arising from a claimed injury. F. The parties hereby agree that from time to time the exclusive list of approved medical providers may be amended. For either party to add an IME to the exclusive list of medical providers, the party must provide notice, in writing, to the other party of its intent to add a physician to the list. Absent a written objection to the other party within thirty (30) calendar days of receipt of the written proposal, the addition will be made. In the event there is an objection, the physician will not be added to the list. A physician may only be deleted from the exclusive list of medical providers if they breach s/he breaches the terms and conditions of the contract with the City or by mutual agreement of the parties.