California Medical Provider Networks

California allows the workers compensation insurers and self-insured employers to utilize a Medical Provider Network (MPN) for the treatment of on-the-job injuries and work-related illnesses. The MPN is an association or network of clinics, physicians, hospitals and other medical providers – under contract with the MPN – who treat workers compensation injuries and occupational illnesses.  The advantage of the MPN to the employer is the employee is treated by a medical provider who specializes in work-related injuries.

Some practitioners have noted with criticism, however, that not all doctors in the network are well-qualified and further indicate that “almost  any physician who is willing to take a discount” can get on the panel; therefore, it is important for employers to make sure that the doctors in their networks understand workers compensation, know how to bill at the OMFS (official medical fee schedule), know how to write reports and return injured workers to modified work. Physicians who are not experienced in the nuances of workers compensation may also not know how to close a case appropriately: Released as Cured; Pre-Injury or Permanent & Stationary / MMI.

California MPNs are designed to provide services throughout the state. It is customary for the MPN to offer:

1. A primary care physician within 15 miles or 30 minutes of the employee’s residence or job site.
2. All other medical services within 30 miles or 60 minutes or the employee’s residence or job site.
3. Emergency medical care services.
4. Medical care in rural areas (they have alternative distance and time standards and, in some situations, allow out-of-network medical providers or non-contract medical providers).
5. Medical care for the employee who is working or traveling outside of their home geographical area (but still within the State of California.)

It should also be noted that all physicians in or out of the MPN must follow the California Treatment Guidelines / Medical Treatment Utilization Schedule Reg. 9710.

The employer has the opportunity to direct the care for 30 days with or without an MPN, but the requirements must be strictly followed or the injured workers regains the right and ability to self procure his own medical provider at the end of 30 days; if the employer has followed the rules, they retain right to direct care for the life of the claim. Stated another way, if an employer has an MPN and did not follow the procedures at time of hire and again at time of injury they lose the right of control. The employer can direct care for the first visit and if they have complied with requirements for providing the employee with MPN information and a list of providers at the time of hire and again at the time of injury they have control for the life of the claim.  If the employee is unhappy with the choice of a physician, they can elect to change doctors but must stay within the MPN.

If the employee is unhappy with the diagnosis or the treatment they receive for their injury, they have the right to ask for a second opinion from another physician within the MPN. The employee is required to make an appointment within 60 days of requesting a second opinion. If the employee is unhappy with both their original doctor’s opinion and the second doctor’s opinion, they are entitled to a third opinion in California.

If the employee is unhappy with the first opinion, second opinion, and third opinion, the employee may file a request for an Independent Medical Review (IMR) with the California Division of Workers Compensation administrative director. The administrative director will assign an independent medical reviewer. The independent medical reviewer will conduct either a physical examination or a medical-records review. If the independent medical reviewer agrees with the employee, the employee can select a physician who does not have to be a part of the MPN. In this case, the employer/insurer is responsible for the medical care cost. The injured worker can request a “QME” (Qualified Medical Examination) and will be provided a panel of 3 to choose from in a given specialty or specialties.

Most MPNs will offer medical management in which a nurse case manager will work with the employee, the employer, and medical providers to get the employee back to work as quickly as feasible. Some MPNs also offer a vocational specialist who works with the employee to retrain them for another occupation when they are physically unable to return to their prior job.

An insurance company or self-insured employer can create their own MPN or join one of the MPNs that have already been established. The benefits to the employer who joins a MPN include:

1. Lower medical cost– The MPN contracts with the medical providers for the cost of the medical fees which are lower than the Medical Fee Schedule used in California. On average the medical fees are approximately 10 percent lower through a MPN.
2. Medical control throughout the claim – When an employer has a MPN and complied with the requirements, the employee must treat within the MPN throughout the life of the claim (with certain exceptions, see above) unless the employee has pre-designated their primary treating physician (the large majority do not). Employers need to make sure this information is provided to all new hires, at the time of hire. They need to be able to document compliance.
3. Elimination of chiropractors and acupuncturists: if the employer has a MPN, the employee can only pre-designate a medical doctor or doctor of osteopath. Without a MPN, the employee can pre-designate their chiropractor or acupuncturist. However, the injured worker can under 4601 request chiropractic care or acupuncture within the MPN. If the MPN has no panel chiropractors or acupuncturists within the given geographic distance they can choose one outside the MPN.

Medical Provider Networks provide medical cost control. The long term impact for the employer is lower overall cost of workers compensation insurance. We recommend for all California employers have a Medical Provider Network, or be affiliate with an insurance company that has one, and make sure you are in compliance with the rules.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing.

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

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