Medical Provider Network in California Workers’ Compensation

Medical Provider Networks (MPNs) are a group of doctors approved by a workers compensation insurance company to provide treatment to injured employees.

Injured workers will generally have to be treated by a doctor within the workers' compensation medical provider network. The only exceptions are if:

  • the employer or insurance company does not provide the injured worker MPN information
  • the appropriate MPN doctor is not available within a reasonable distance from the injured worker

After the first medical visit following an injury, the injured worker can select any doctor within the medical provider network.

If an injured worker is not satisfied with the treatment program of the treating physician, he or she can request a second opinion from another doctor. If the injured worker disagrees with the second opinion doctor, he or she can request a third opinion.

If the injured worker disagrees with the third opinion, he or she can request an Independent Medical Review.

If any doctor disagrees with the opinion of the current treating physician, the injured worker can change treating doctors.

In this article, our California personal injury attorneys will explain:

1. What are Medical Provider Networks?

Medical treatment is a required benefit for injured workers in California workers' compensation.1 However, an injured worker cannot be treated by just any doctor. If an insurer or employer establishes a Medical Provider Network (MPN), an injured worker must be treated by a doctor within the network.2

Each employer can establish their own MPN, but the network must give injured workers access to medical treatment. The network must have enough doctors to treat common work injuries in all geographic areas of California where an injured worker may live.3

The MPNs include

  • physicians and surgeons holding an M.D. or D.O. degree,
  • psychologists,
  • acupuncturists,
  • optometrists,
  • dentists,
  • podiatrists, and
  • chiropractic practitioners licensed by California state law.4

Each MPN is required to have a list of doctors available online.5 The online list gives injured workers the ability to schedule appointments without waiting for the insurance company to provide the information, which could cause significant delays.

The Department of Workers' Compensation provides a list of current MPNs that are active in the state.

Example: Andrea injures her back at work. She is sent to an urgent care clinic by her employer. She is scheduled for a second visit. Andrea is not very happy with the treatment she receives at the industrial clinic.

Before she goes back to the industrial clinic, Andrea receives a letter from the insurance company that has the web address of the employer's MPN. She goes online and finds a different doctor to be her treating physician. Andrea cancels her clinic visit and calls to schedules her first visit with her new treating doctor.

The insurance company must accept Andrea's selection because the doctor is in the MPN.

2. MPN doctor and treatment guidelines

All treatment in workers' compensation is based on medical treatment guidelines that determine “the frequency, duration, intensity, and appropriateness of all treatment procedures and modalities commonly performed in workers compensation cases.”6 This is for the purpose of ensuring that injured workers receive a standardized level of care.

All MPN doctors must follow the medical treatment guidelines through a process is called Utilization Review (UR).7 Medical treatment requests are sent to an independent physician that can approve, modify, or deny the treatment request.8

The MPN and Utilization Review work together to direct an injured worker's medical treatment. The MPN deals with who is going to treat an injured worker, while UR deals with what treatment the injured worker can receive.

If the employer has an issue with treatment recommended by the treating physician, the only option is to go through the Utilization Review process.9

3. The treating doctor in the MPN

The treating doctor's opinion about the injured worker's injury is one of the most important parts of the workers' compensation process. The duties of a treating doctor in the MPN include determining:

  • if there is an injury
  • if there is a cumulative trauma
  • temporary disability
  • modified work or light duty
  • permanent and stationary date
  • permanent disability
  • apportionment

The treating doctor directs an injured worker's medical care. The doctor will determine the injured worker's ability to work during the injury and the periods of temporary disability he or she should receive. The treating doctor will also issue an opinion on when the injured worker's condition has stabilized and the amount of permanent disability he or she has suffered.

Other than a doctor who sees an injured worker for an evaluation only, called a med-legal examination, the treating doctor determines the dollar value of a case.

Example: Nicholas injured his cervical spine nine months ago. His doctor initially said Nicolas was temporarily disabled for six weeks. He then said Nicholas could go back to work with light duty. A different treating doctor may have given Nicholas a longer or shorter period of temporary disability.

Two weeks ago, the doctor said that Nicholas condition has stabilized, and that he had 17% permanent disability to his cervical spine. The percentage rating is converted to a dollar value. Another doctor may have given Nicholas more or less permanent disability, which would affect the value of his case.

If the employee is killed on the job, there will not be an MPN issue since there is no medical treatment provided. The case is considered a death benefits case.

4. What is an MPN notice?

When an injury is reported, an employer must provide notice to the injured worker that there is an MPN.10

The MPN notice must include:

  • how to reach the MPN contact person for assistance in finding and scheduling appointments
  • description of MPN services
  • how to access the MPN directory
  • how to access initial care
  • how to choose a doctor within the MPN
  • what to do if there is trouble scheduling an appointment
  • how to change physicians within the MPN
  • how to obtain a referral to a specialist
  • how to use the second or third opinion process
  • how to receive MPN independent medical review
  • description of continuity of care standards

An injured worker that is treating with an MPN doctor will receive mileage reimbursement. The reimbursement covers

  • trips to and from doctor's appointments,
  • physical therapy,
  • pharmacies, and
  • any other travel related to his or her work injury.

An injured worker that has a complaint about accessing or using an MPN can file a complaint.11

5. How to choose a doctor within in the MPN

After an injured worker files a claim for workers' compensation benefits, he or she will need to use the MPN.

When the injured employee notifies an employer about an injury, the employer shall arrange the first medical visit.12

After the first visit, the employer is required to notify the injured worker of the MPN, how to find a list of providers, and his or her right to change the treating physician.13

Example: Randy injures his shoulder at work and notifies his employer. The employer sends Randy to the doctor the same day. A few days later, Randy receives information in the mail from the insurance company that there is an MPN.

Randy accesses the MPN list online and chooses a treating doctor who will be in charge of Randy's treatment for the length of his claim.

The failure of an employer to provide the list does not mean that the injured employee can be treated by a doctor outside of the MPN.14

6. Accessibility of the MPN

An MPN must have:

  • at least three doctors in each specialty to treat common injuries within 30 minutes or 15 miles of all covered employees and act as the treating physician
  • specialists within 60 minutes or 30 miles of all covered employees15

If a doctor that meets these requirements is not available, the employee may be allowed to treat outside the MPN.16

If the injured worker requires treatment from a specialist that is not in the MPN, treatment outside the MPN is determined on a case by case basis.17 The recommendation for a specialist will come from the treating physician.

A doctor outside of the MPN still must follow procedures for workers' compensation treatment, including treatment requests through Utilization Review and accepting payment through the workers' compensation insurance carrier.

Example: Erica is hit on the head and injured while working at a construction site. She suffers a concussion.

Erica tries to select a neurologist from the MPN list to treat her. But she can't locate one within 30 miles of her work or home. Erica may be allowed to be treated by a doctor outside of the MPN.

An important factor for Erica to consider is whether the neurologist she selects will agree to see her. Many doctors may not want to take an injured worker's case due to having to follow workers' compensation procedures.

If an injured worker believes he or she is entitled to be treated by a doctor outside the MPN, the issue may need to go to a workers compenstaion trial.

7. Treating with doctors removed from the MPN

If a doctor is removed from the MPN, the injured worker can continue to be treated by his or her doctor depending on the condition:

  • for an acute condition (less than 90 days) the injured worker can be treated for the duration of the condition
  • for a serious chronic condition, up to 12 months
  • for a terminal illness, for the duration of the illness
  • for performance of surgery, up to 180 days18

8. Getting a second and third opinion

If an injured worker disputes his or her treating physician's medical diagnosis or treatment recommendation, a second and third opinion is available.19

The process for an injured worker to dispute the treating physician is to:

  • notify the employer that he or she is disputing the primary physician and wants a second opinion
  • select a second opinion doctor from the MPN
  • make an appointment within 60 days
  • inform the insurance company of the appointment20

The insurance company will provide a list of second opinion doctors and send all relevant medical records to the selected second opinion doctor. 21

If an injured worker does not make an appointment within 60 days of getting the list, he or she has waived the right to dispute it.22

The second and third opinion doctors shall issue opinions within 20 days.23

Example: Joanne injures her right arm at work. She has pain in her right elbow but does not believe her doctor is providing her with the right treatment.

Joanne notifies the insurance company that she wants a second opinion. She receives a list of doctors, selects one, and makes an appointment.

The second opinion doctor requests additional treatment for Joanne's elbow. Joanne can now switch her treating doctor to the second opinion doctor or any other doctor.

If the second or third opinion doctor issues a decision favorable to the injured worker, the injured worker can switch the treating doctor to the second or third opinion doctor or another doctor in the MPN.24

9. What is independent medical review?

If the injured worker still disputes a diagnosis or treatment after getting a third opinion, he or she can obtain an independent medical review.25 The independent doctor will continue to follow the same standards as in Utilization Review. 26

The independent review doctor will review all of the injured worker's relevant medical records, may examine the injured worker if he or she requests, perform any necessary diagnostic tests, and issue a report within 30 days.27

The independent medical review in Utilization Review is a completely different process. The Utilization Review process deals with whether treatment is appropriate. The MPN issue is related to whether the doctor is the appropriate treater.

The report is sent to the administrative director, who will notify the injured worker. The independent medical review doctor's opinion is the final opinion.28 If the doctor approves a treatment that was previously denied, the injured worker can be treated by any doctor, in or out the MPN. The doctor still must follow the treatment diagnosis guidelines.29

No other examinations can be used to resolve a diagnosis or treatment issue between the injured worker and treating doctor.30

It is unlikely an injured worker will go through the second opinion process and beyond due to the delay in receiving treatment. An injured worker who wants a second opinion will likely have to wait at least 30 days for the second report to be issued from the time he or she starts the process. It may be significantly longer than that.

Going to a doctor for a third opinion and independent medical review can take many months and may not be practical when the injured worker has a serious health issue.

10. The reason for Medical Provider Networks

Medical Provider Networks are an effort by insurance companies to control the cost of medical care in the workers' compensation system. The insurance companies may try excluding certain doctors from its network, believing the doctor requests excessive medical treatment or gives too much permanent disability.

But because MPN's have a requirement to be large enough to treat all injured workers, limiting the doctors is often not practical. Therefore, the insurance company will initially send an injured worker to a doctor very favorable to the insurance company and hope the injured worker takes no further action.

For that reason alone, it is to the benefit of every injured worker to change doctors within the MPN after the initial visit to obtain fair treatment and compensation.

Call us for help...

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Call us at (855) LAW-FIRM

For help with filing a workers compensation claim in Calfornia, completing workers comp forms or appealing a denial of benefits, contact us at (855) LAW-FIRM. Our firm helps police officers, firefighters and other workers to get compensation for their job-related injuries.

Legal References:

  1. Cal. Lab. Code § 4600.

  2. Cal. Lab. Code §4616(a)(1).

  3. Cal. Lab. Code §4616(a)(1).

  4. Cal. Lab. Code § 3209.3.

  5. Cal. Lab. Code § 4616(a)(4).

  6. Cal. Lab. Code § 5307.27(a).

  7. Cal. Lab. Code § 4616(e).

  8. Cal. Lab. Code § 4616(f).

  9. Gregory Parent v. WCAB (2017) 82 Cal. Comp. Cases 155.

  10. Cal. Code Regs., tit. 8, § 9767.12

  11. Cal. Code Regs., tit. 8 § 9767.16.5

  12. Cal. Lab. Code § 4616.3(a).

  13. Cal. Lab. Code § 4616.3(b).

  14. Cal. Lab. Code § 4616.3(b).

  15. Cal. Code Regs., tit. 8 § 9767.5, subd. (a).

  16. Cal. Code Regs., tit. 8 § 9767.5, subd. (c).

  17. Cal. Lab. Code § 4616.3(d)(2).

  18. Cal. Lab. Code § 4616.2(d).

  19. Cal. Lab. Code § 4616.3(d).

  20. Cal. Code Regs., tit. 8 § 9767.7, subd. (b).

  21. Id.

  22. Cal. Code Regs., tit. 8 § 9767.7, subd. (d).

  23. Cal. Code Regs., tit. 8 § 9767.7, subd. (f).

  24. Cal. Code Regs., tit. 8 § 9767.7, subd. (g).

  25. Cal. Lab. Code § 4616.4(b).

  26. Cal. Lab. Code § 4616.4(b).

  27. Cal. Lab. Code § 4616.4(f).

  28. Cal. Lab. Code § 4616.4(h).

  29. Cal. Lab. Code § 4616.4(i).

  30. Cal. Lab. Code § 4616.6.

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