California Medical Providers Mystified By MPNs (Medical Provider Networks)
by Richard J Boggan JD
March 24, 2009
I continually get questions from Lien Claimants who state that their medical bills are being denied because they treated outside an MPN, asking
what recourse do they have. With the creation of MPNs one would have to think that since they were created for the benefit the Insurance
Carriers that all rules would be followed, however this is not the case, as cases continually come down where medical providers who treat
outside the MPNs are getting paid.
A medical provider network (MPN) is an entity or group of health care providers set up by an insurer or self-insured employer and approved
by DWC's administrative director to treat workers injured on the job. Under state regulations, each MPN must include a mix of doctors
specializing in work-related injuries and doctors with expertise in general areas of medicine. MPNs are required to meet access to care standards
for common occupational injuries and work-related illnesses.
Helpful Hints
1. Look at the date of injury if it is before the creation of the MPN then the injured worker must have signed a document transferring the
medical treatment into the MPN
2. See if the injury and or treatment was denied, this shows that the injured worker was not offered adequate medical treatment within the
MPN and therefore the employer is responsible for treatment outside the MPN.
3. The law allows the injured to treat outside the MPN if the employer did not give the injured worker notice of the MPN and his or her rights
under the MPN.
The following are some cases that have been decided where the medical provider treated outside the MPN and reimbursement was ordered.
• Bruce Knight, United Parcel Service; and Liberty Mutual Insurance Company October 10, 2006 71 Cal. Comp. Cases 1423
“The Board held that an employer or insurer's failure to provide required notice to an employee of rights under the MPN (medical provider
network) that results in a neglect or refusal to provide reasonable medical treatment renders the employer or insurer liable for reasonable medical
treatment self-procured by the employee.”
• Jennifer Balkowitsch, Applicant v. Home Depot, PSI, adjusted by Sedgwick Claims Management Services, Defendants, 2008 Cal. Wrk.
Comp. P.D. LEXIS 567, Opinion Filed August 11, 2008
“We agree with applicant's contentions that the record demonstrates that defendant neglected or refused to provide reasonable medical treatment
through its MPN. Applicant testified without contradiction that five of the MPN physicians she contacted from the list sent to her by
defendant refused to accept her as a patient, and defendant offered no evidence to show that there were a sufficient number of other physicians
willing to accept applicant as a patient who were made available to her within the applicable MPN access standards.
The court further stated:
“However, a failure to comply with applicable statutes and regulations that results in a neglect or refusal to provide reasonable medical
treatment renders the employer or insurer liable for medical treatment self-procured by the injured worker. (Knight v. United Parcel Service
(2006) 71 Cal.Comp.Cases 1423 (Appeals Board en banc) (Knight).)”
• Joaquin Valencia, Applicant v. Taylor Fresh Foods, Zurich North America, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS 596, Opinion
Filed August 6, 2008
Applicant then commenced treatment with Dr. Davis. The only objection made by defendant when applicant commenced treatment with Dr.
Davis was that he was not a member of defendant's Medical Provider Network (MPN hereinafter). Defendant did not raise the issue of
applicant's prior discharge from treatment by Salinas Urgent Care until the Mandatory Settlement Conference. When the matter proceeded to
trial, defendant did not introduce any notice letters regarding the MPN process. Applicant testified in unrebutted, uncontradicted fashion that he
did not receive any notices about MPN physicians or about transfer of care or continuity of care. Applicant received no information about how
to object to any opinion by the company doctor or MPN physician.
• Carlos S. Gonzales, Applicant v. Gilberto Portillo Painting, State Compensation Insurance Fund, Defendants, 2008 Cal. Wrk. Comp. P.D.
LEXIS 463, Opinion Filed July 2, 2008 WCAB held that applicant with 6/25/2005 left hip, back, upper and lower extremity, neck, left eye, and
psyche injuries and injuries in the form of headaches and sleep disorder, was entitled to treat outside defendant's medical provider network
(MPN) and that WCJ properly relied on treating physician's report to award benefits, when defendant did not comply with Labor Code § 3550
as it failed to provide applicant with adequate notice of MPN physicians, and did not request an expedited hearing to compel applicant to treat
within MPN; WCAB found that, since defendant did not object to treating physician's report at trial, defendant waived issue of admissibility.
• Courtney Penebaker, Applicant v. CIGNA Healthcare, CIGNA Property & Casualty Company/ACE USA, Defendants, 2008 Cal. Wrk.
Comp. P.D. LEXIS 475, Opinion Filed June 20, 2008
“ The was no evidence presented to show that the single medical facility was able to treat patients with MRSA or prone to skin infections; nor
any indication of what facilities would be available to respond to any MRSA flare-up in response to either surgical procedure being
recommended for Applicant, nor that any physician at the facility has the skill necessary to treat Applicant's special medical conditions.
Despite the Defendant insisting that Applicant treat within their MPN starting in January 2007, no questions were asked of the AME, by letter
or at the deposition on October 23, 2007, about the appropriateness of treatment at the MPN facility.
Defendant has not met their burden of showing that they have offered appropriate medical treatment within their MPN.
The Defendants' Petition also contends that the wrong specialty was assigned to the panel QME. The applicant's attorney requested a specialty
in chiropractic medicine and Defendants contend that a medical doctor should be the panel QME. The Defendants cite ACOEM Guidelines in
support of their argument.”
• Jose Garrido, Applicant v. San Francisco Marriott, PSI, administered by Marriott Claims Services, Defendants, 2008 Cal. Wrk. Comp. P.D.
LEXIS 332, Opinion Filed April 30, 2008
Medical-Legal Procedure--Panel Qualified Medical Evaluations--Medical Provider Networks--WCAB denied defendant's request for removal
from WCJ's Order allowing applicant with 3/16/2007 injuries to left shoulder, neck, back and left leg to undergo a panel qualified medical
evaluation with a chiropractor outside defendant's medical provider network (MPN) after objecting to findings of treating physician within
MPN, and held that applicant was not required to exhaust all remedies set forth in MPN statutes (Labor Code § 4616 et seq.) before requesting
a panel qualified medical evaluation pursuant to Labor Code § 4062.2 , and that applicant was entitled to choose a chiropractor as a qualified
medical evaluator, rather than a medical doctor.
The current version of Labor Code Section 4062.2 does not state anything with respect to disputes between the parties regarding the medical
specialty to be assigned by the administrative director. It is clear that the party submitting the request shall designate the specialty of the
medical evaluator and the specialty of the medical evaluator requested by the other party, if it has been made known to the party submitting the
request.
In this case, the evidence showed that the applicant's attorney requested a specialty in chiropractic medicine. Defendants sent written objections
after the panel QME in chiropractic medicine was sent by the administrative director contending that a medical doctor in orthopedic medicine
should be the panel QME.
After considering the arguments, I decided that in light of the absence of any language in Labor Code Section 4062.2, I have no statutory
authority to allow me to change the medical specialty designation of the panel QME from the request made by applicant and his attorney.
Therefore, the panel QME is Dr. Greensides, a chiropractor. If Dr. Greensides feels that there are issues outside his expertise, he does have the
right to select consultants in those specialties to examine the applicant and issue reports that he could review and incorporate into his own
reports.
• Walter Roque, Applicant v. Louise's Trattoria, Liberty Mutual Insurance Company, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS 349,
Opinion Filed April 21, 2008
Here, we conclude that defendant failed to meet its burden of proving, pursuant to section 3202.5, that it provided applicant with the required
notices to transfer his medical treatment into its MPN. Defendant's sent its initial MPN notice to applicant in March 2005. However, that
notice was only in English and not in Spanish. It appears that defendant did not correct this notice deficiency until December 2006, more than a
year and half later, when it sent applicant a MPN transfer notice in Spanish. Furthermore, in January 2007, defendant sent applicant a notice
that it was transferring his medical treatment to Dr. Rahimi. However, that notice was not sent to applicant in Spanish, only in English, and
defendant did not prove that it sent a copy to applicant's treating physician, Dr. Konstat, as required pursuant to Administrative Director's Rule
9767.9, subd. (f). (Cal. Code Regs. tit. 8, § 9767.9, subd. (f).)
• Mitzi L. Thomas, Applicant v. Bakers Burgers, Inc., State Compensation Insurance Fund, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS
351, Opinion Filed April 21, 2008 Medical Provider Networks-Medical Treatment-WCAB held that applicant with 1/7/2006 right knee injury
was entitled to seek medical treatment outside defendant's medical provider network (MPN) and that defendant was liable for self-procured
medical expenses, when defendant did not provide timely authorization or provision of an MRI of applicant's right knee, and provided
inadequate medical treatment within MPN.
To summarize, if the injured worker has treated with a provider outside the MPN, then one of the requirements as to notice, providing
reasonable medical treatment and compliance with the applicable statutes have may not been met. Therefore, your first approach is to find out
which element is present in your case, notice, reasonable medical treatment, and or denial of injury or medical treatment.
by Richard J Boggan JD
March 24, 2009
I continually get questions from Lien Claimants who state that their medical bills are being denied because they treated outside an MPN, asking
what recourse do they have. With the creation of MPNs one would have to think that since they were created for the benefit the Insurance
Carriers that all rules would be followed, however this is not the case, as cases continually come down where medical providers who treat
outside the MPNs are getting paid.
A medical provider network (MPN) is an entity or group of health care providers set up by an insurer or self-insured employer and approved
by DWC's administrative director to treat workers injured on the job. Under state regulations, each MPN must include a mix of doctors
specializing in work-related injuries and doctors with expertise in general areas of medicine. MPNs are required to meet access to care standards
for common occupational injuries and work-related illnesses.
Helpful Hints
1. Look at the date of injury if it is before the creation of the MPN then the injured worker must have signed a document transferring the
medical treatment into the MPN
2. See if the injury and or treatment was denied, this shows that the injured worker was not offered adequate medical treatment within the
MPN and therefore the employer is responsible for treatment outside the MPN.
3. The law allows the injured to treat outside the MPN if the employer did not give the injured worker notice of the MPN and his or her rights
under the MPN.
The following are some cases that have been decided where the medical provider treated outside the MPN and reimbursement was ordered.
• Bruce Knight, United Parcel Service; and Liberty Mutual Insurance Company October 10, 2006 71 Cal. Comp. Cases 1423
“The Board held that an employer or insurer's failure to provide required notice to an employee of rights under the MPN (medical provider
network) that results in a neglect or refusal to provide reasonable medical treatment renders the employer or insurer liable for reasonable medical
treatment self-procured by the employee.”
• Jennifer Balkowitsch, Applicant v. Home Depot, PSI, adjusted by Sedgwick Claims Management Services, Defendants, 2008 Cal. Wrk.
Comp. P.D. LEXIS 567, Opinion Filed August 11, 2008
“We agree with applicant's contentions that the record demonstrates that defendant neglected or refused to provide reasonable medical treatment
through its MPN. Applicant testified without contradiction that five of the MPN physicians she contacted from the list sent to her by
defendant refused to accept her as a patient, and defendant offered no evidence to show that there were a sufficient number of other physicians
willing to accept applicant as a patient who were made available to her within the applicable MPN access standards.
The court further stated:
“However, a failure to comply with applicable statutes and regulations that results in a neglect or refusal to provide reasonable medical
treatment renders the employer or insurer liable for medical treatment self-procured by the injured worker. (Knight v. United Parcel Service
(2006) 71 Cal.Comp.Cases 1423 (Appeals Board en banc) (Knight).)”
• Joaquin Valencia, Applicant v. Taylor Fresh Foods, Zurich North America, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS 596, Opinion
Filed August 6, 2008
Applicant then commenced treatment with Dr. Davis. The only objection made by defendant when applicant commenced treatment with Dr.
Davis was that he was not a member of defendant's Medical Provider Network (MPN hereinafter). Defendant did not raise the issue of
applicant's prior discharge from treatment by Salinas Urgent Care until the Mandatory Settlement Conference. When the matter proceeded to
trial, defendant did not introduce any notice letters regarding the MPN process. Applicant testified in unrebutted, uncontradicted fashion that he
did not receive any notices about MPN physicians or about transfer of care or continuity of care. Applicant received no information about how
to object to any opinion by the company doctor or MPN physician.
• Carlos S. Gonzales, Applicant v. Gilberto Portillo Painting, State Compensation Insurance Fund, Defendants, 2008 Cal. Wrk. Comp. P.D.
LEXIS 463, Opinion Filed July 2, 2008 WCAB held that applicant with 6/25/2005 left hip, back, upper and lower extremity, neck, left eye, and
psyche injuries and injuries in the form of headaches and sleep disorder, was entitled to treat outside defendant's medical provider network
(MPN) and that WCJ properly relied on treating physician's report to award benefits, when defendant did not comply with Labor Code § 3550
as it failed to provide applicant with adequate notice of MPN physicians, and did not request an expedited hearing to compel applicant to treat
within MPN; WCAB found that, since defendant did not object to treating physician's report at trial, defendant waived issue of admissibility.
• Courtney Penebaker, Applicant v. CIGNA Healthcare, CIGNA Property & Casualty Company/ACE USA, Defendants, 2008 Cal. Wrk.
Comp. P.D. LEXIS 475, Opinion Filed June 20, 2008
“ The was no evidence presented to show that the single medical facility was able to treat patients with MRSA or prone to skin infections; nor
any indication of what facilities would be available to respond to any MRSA flare-up in response to either surgical procedure being
recommended for Applicant, nor that any physician at the facility has the skill necessary to treat Applicant's special medical conditions.
Despite the Defendant insisting that Applicant treat within their MPN starting in January 2007, no questions were asked of the AME, by letter
or at the deposition on October 23, 2007, about the appropriateness of treatment at the MPN facility.
Defendant has not met their burden of showing that they have offered appropriate medical treatment within their MPN.
The Defendants' Petition also contends that the wrong specialty was assigned to the panel QME. The applicant's attorney requested a specialty
in chiropractic medicine and Defendants contend that a medical doctor should be the panel QME. The Defendants cite ACOEM Guidelines in
support of their argument.”
• Jose Garrido, Applicant v. San Francisco Marriott, PSI, administered by Marriott Claims Services, Defendants, 2008 Cal. Wrk. Comp. P.D.
LEXIS 332, Opinion Filed April 30, 2008
Medical-Legal Procedure--Panel Qualified Medical Evaluations--Medical Provider Networks--WCAB denied defendant's request for removal
from WCJ's Order allowing applicant with 3/16/2007 injuries to left shoulder, neck, back and left leg to undergo a panel qualified medical
evaluation with a chiropractor outside defendant's medical provider network (MPN) after objecting to findings of treating physician within
MPN, and held that applicant was not required to exhaust all remedies set forth in MPN statutes (Labor Code § 4616 et seq.) before requesting
a panel qualified medical evaluation pursuant to Labor Code § 4062.2 , and that applicant was entitled to choose a chiropractor as a qualified
medical evaluator, rather than a medical doctor.
The current version of Labor Code Section 4062.2 does not state anything with respect to disputes between the parties regarding the medical
specialty to be assigned by the administrative director. It is clear that the party submitting the request shall designate the specialty of the
medical evaluator and the specialty of the medical evaluator requested by the other party, if it has been made known to the party submitting the
request.
In this case, the evidence showed that the applicant's attorney requested a specialty in chiropractic medicine. Defendants sent written objections
after the panel QME in chiropractic medicine was sent by the administrative director contending that a medical doctor in orthopedic medicine
should be the panel QME.
After considering the arguments, I decided that in light of the absence of any language in Labor Code Section 4062.2, I have no statutory
authority to allow me to change the medical specialty designation of the panel QME from the request made by applicant and his attorney.
Therefore, the panel QME is Dr. Greensides, a chiropractor. If Dr. Greensides feels that there are issues outside his expertise, he does have the
right to select consultants in those specialties to examine the applicant and issue reports that he could review and incorporate into his own
reports.
• Walter Roque, Applicant v. Louise's Trattoria, Liberty Mutual Insurance Company, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS 349,
Opinion Filed April 21, 2008
Here, we conclude that defendant failed to meet its burden of proving, pursuant to section 3202.5, that it provided applicant with the required
notices to transfer his medical treatment into its MPN. Defendant's sent its initial MPN notice to applicant in March 2005. However, that
notice was only in English and not in Spanish. It appears that defendant did not correct this notice deficiency until December 2006, more than a
year and half later, when it sent applicant a MPN transfer notice in Spanish. Furthermore, in January 2007, defendant sent applicant a notice
that it was transferring his medical treatment to Dr. Rahimi. However, that notice was not sent to applicant in Spanish, only in English, and
defendant did not prove that it sent a copy to applicant's treating physician, Dr. Konstat, as required pursuant to Administrative Director's Rule
9767.9, subd. (f). (Cal. Code Regs. tit. 8, § 9767.9, subd. (f).)
• Mitzi L. Thomas, Applicant v. Bakers Burgers, Inc., State Compensation Insurance Fund, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS
351, Opinion Filed April 21, 2008 Medical Provider Networks-Medical Treatment-WCAB held that applicant with 1/7/2006 right knee injury
was entitled to seek medical treatment outside defendant's medical provider network (MPN) and that defendant was liable for self-procured
medical expenses, when defendant did not provide timely authorization or provision of an MRI of applicant's right knee, and provided
inadequate medical treatment within MPN.
To summarize, if the injured worker has treated with a provider outside the MPN, then one of the requirements as to notice, providing
reasonable medical treatment and compliance with the applicable statutes have may not been met. Therefore, your first approach is to find out
which element is present in your case, notice, reasonable medical treatment, and or denial of injury or medical treatment.
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