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Medical Provider Network Changes

By W. Rod McClelland, Jr.

 

MPNs allow for more control of medical treatment when the industrial injury claim has been accepted.  Greater medical control allows claims to close faster.  Claims must be closed before the unit stat filing date to avoid the claim being factored into a new experience modifier.  The unit stat filing date is six (6) months prior to the policy expiration date.

 

An employee still has the right to be treated by a pre-designated physician from the date of injury, if the employee has health care coverage for non-occupational injuries or illness on the date of injury.  However, if the employer objects to the employee’s selection of a physician, because the physician is not an MPN member, and the Judge makes a final determination against the employee after a trial, the employer is not liable for treatment provided by that physician, or for any consequences of that treatment.

 

This allows the employer to present a very strong argument that the injured worker is not entitled to any temporary disability benefit.  At a minimum, the threat of no temporary disability benefits, and the fact that a non MPN report cannot be the sole basis of an award, should be used to force an injured worker to treat within the MPN.

 

However, if the employer objects to the employee’s selection of a physician because the physician is not an MPN member, and the employee prevails, the employee may continue treating with that physician notwithstanding Labor Code 4616.2.  The physician must submit a report within five (5) working days of the initial examination; otherwise, neither the employer nor the employee is required to pay for services provided prior to the date the physician’s report was submitted.

 

Whether an employee can be required to treat within an MPN may be the subject of an expedited hearing.  No other matter may be heard in the industrial injury case, until the MPN treatment issue is resolved.  Moreover, failure to provide certain notices of the MPN and the right to change physicians are not a basis to treat outside of the MPN, unless it is shown the failure resulted in a denial of medical care.

 

MPN treatment disputes are resolved in the following order:

 

a.    First MPN opinion;

 

b.    Second MPN opinion;

 

c.    Third MPN opinion;

 

d.    IMR review if the dispute is not resolved by MPN physician reporting.

 

 

MPN approval now lasts four (4) years.  As of January 1, 2014, all existing approved MPNs are deemed approved for four (4) years from the date of the last application or modification approval.  Upon a showing that the MPN was approved or deemed approved by the Administrative Director, there shall be a conclusive presumption the network was validly formed.  Unless suspended or revoked, the Administrative Director’s approval of a MPN is binding on all persons and courts and a determination of the Administrative Director may be appealed only by filing an original proceeding before the Reconsideration Unit of the Board.

 

Any entity that provides physician services may apply to become an MPN.  The goal to have at least 25% non-occupational physicians was deleted.  Every MPN must establish and follow procedures to continuously review quality of care, performance of medical personnel, utilization of services, facility and costs.  Physicians will be included in an MPN only if they provide a written acknowledgement electing to be in the network.

 

All this means that MPNs provide a strategic advantage for adjusting industrial injury cases.  Prevailing by making the initial objection to the employee’s selection of a physician because the physician is not an MPN member allows the employer to avoid liability for treatment provided by that physician and any consequences of that treatment.  This includes temporary disability benefits.

 

Moreover, a non MPN report cannot be the sole basis of an award.  Furthermore, whether an employee can be required to treat within an MPN may be the subject of an expedited hearing.

 

At YRULEGUI & ROBERTS, we are very familiar with the strategic benefits discussed in this article. Please contact our office with any questions.

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