Workers Comp: Lesson 5 Medical Provider Networks (MPN)

Workers Comp: Lesson 5 Medical
Provider Networks (MPN)
www.workcompliens.com
October 06, 2014
MPNs (Medical Providers Networks)
Accessibility – to ensure the injured worker has
accessibility to medical treatment. -- if not can treat
outside MPN.
-Offer of reasonable medical treatment
-Transfer of medical treatment
-Hold harmless clause
- Missing date of injury if prior to 2005 – do not see it as
often as prior years but still there.
- Defense Burden of Proof
- Denied Injury Issues of MPN
- After Proving Treatment Outside MPN – Causation /
Medical Necessity and Reasonable Reimbursements
Denied Case and MPN
Significant Panel Decision
Eun Jae Kim v. B.C.D. Tofu House, Inc.; Cypress Insurance Company, et. all February 7, 2014
Case No. ADJ9086333 79 Cal. Comp. Cases 140
Employee must treat in the employer’s medical provider network during the 90day delay period, under Labor Code section 5402(b), that the employer has to
investigate and determine whether to accept or reject the claim.
Do not let this become the main issue in a d denied case if you have
no treatment prior to denial of injury quickly dispense with this
issue or if have little treatment
Date if Injury Prior to 2005
Providers normally missed this it was prevalent a
lot in years past, but will see it on old files still to
this day – Always check the date of injury if
prior to 2005 there was no MPNs then and the
defense would have the burden of proof to show
that the treatment was transferred into the MPN.
MPN Burden of Proof
MPN issues at the WCAB are like no other as
the WCAB hand out sanctions on this issue so
over preparedness and development of the
issues at the collection stages are essential.
One of the few issues where the defense has the initial burden of proof
therefore the demand for documentation and proof at the collection stage
is necessary – it also helps at the WCAB to show you requested
documentation and it was not supplied therefore the necessity of filing a
lien and DOR – may prevent the issue of sanctions if bad case
Burden of Proof / Judge Prejudged
MPN Issue
“However, as to the existence and validity of the MPN, defendant listed only one
document in the Pretrial Conference Statement that appears to be relevant, an "initial
letter re MPN" dated September 12, 2012. Defendant holds the affirmative of the issue
of the existence and validity of the MPN and thus the burden of proof rests upon
defendant (Labor Code § 5705). LC's burden of disputing the MPN arises only after
defendant has proved its existence and validity. If defendant failed to notify applicant
of his rights under the MPN and that failure resulted in neglect or refusal to provide
reasonable medical treatment, defendant may be liable for self-procured treatment
“(Knight v. United Parcel Service (2006) 71 Cal.Comp.Cases 1423 [Appeals Board en
banc]).
MARIAM DAVTYAN vs THE VONS COMPANIES, INC., Permissibly Self-Insured,
Case June 2014 No. ADJ8870233 (Los Angeles District Office) OPINION AND
ORDER GRANTING PETITION FOR REMOVAL AND Decsion
9767.9. Transfer of Ongoing Care
into the MPN
9767.9 (j) If the treating physician does not agree
with the employer's or insurer's determination
that the injured covered employee's medical
condition does not meet the conditions set forth
in subdivisions (e)(1) through (e)(4), the transfer
of care shall not go forward until the dispute is
resolved.
Big issue for providers, they are ignoring these notice
to transfer into MPN when all they had to do was
object to make it an none issue and continue to treat
until resolved by the WCAB
Section 4616.2(d)(3)
Section 4616.2(d)(3) states that a medical provider terminated by the MPN may continue
treatment when any of the following are present: "(A) An acute condition. An acute condition is a
medical condition that involves a sudden onset of symptoms due to an illness, injury, or other
medical problem that requires prompt medical attention and that has a limited duration.
Completion of treatment shall be provided for the duration of the acute condition. (B) A serious
chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or
other medical problem or medical disorder that is serious in nature and that persists without full
cure or worsens over an extended period of time or requires ongoing treatment to maintain
remission or prevent deterioration. Completion of treatment shall be provided for a period of time
necessary to complete a course of treatment and to arrange for a safe transfer to another provider,
as determined by the insurer or employer in consultation with the injured employee and the
terminated provider and consistent with good professional practice. Completion of treatment
under this paragraph shall not exceed 12 months from the contract termination date. (C) A
terminal illness. A terminal illness is an incurable or irreversible condition that has a high
probability of causing death within one year or less. Completion of treatment shall be provided for
the duration of a terminal illness. (D) Performance of a surgery or other procedure that is
authorized by the insurer or employer as part of a documented course of treatment and has been
recommended and documented by the provider to occur within 180 days of the contract's
termination date."
Babbit v. Ow Jing, 72 CCC 70, 73
(WCAB en banc 2007)
”… that a defendant may satisfy its obligation to provide
reasonable medical treatment through an MPN in cases where
the date of injury and/or the award of future medical treatment
are prior to January 1, 2005. This is because the MPN statutes
make only a procedural change in the law by allowing the
provision of reasonable medical treatment through an MPN and
do not affect any substantive rights. Thus, we hold that a
defendant may satisfy its obligation under section 4600 to
provide reasonable medical treatment by transferring an injured
worker into an authorized MPN in conformity with applicable
statutes and regulations regardless of the date of injury or the
date of an award of future medical treatment.
Notice of Transfer
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.
Notice of Transfer
CCR § 9767.9(f) If the employer or insurer decides to transfer
the covered employee's medical care to the medical provider
network, the employer or insurer shall notify the covered
employee of the determination regarding the completion of
treatment and the decision to transfer medical care into the
medical provider network. The notification shall be sent to the
covered employee's residence and a copy of the letter shall be
sent to the covered employee's primary treating physician. The
notification shall be written in English and Spanish and use
layperson's terms to the maximum extent possible.
Defective Notices –Resulting In
Unreasonable Offer of Care
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.
Equivocal and inadequate offer of
medical treatment
If the employer made an equivocal and
inadequate offer of medical treatment, the
employee could select his or her own physician
and obtain reimbursement for the reasonable cost
of reasonable self-procured medical treatment
pursuant to section 4600. Voss v. Workers'
Comp. Appeals Bd. (1974) 10 Cal.3d 583, 588
[516 P.2d 1377, 111 Cal. Rptr. 241] [39
Cal.Comp.Cases 56.
Equivocal and inadequate offer of
medical treatment
Voss v. Workers' Comp. Appeals Bd., (1974)10 Cal. 3d 583, 588; 516 P.2d
1377, 1380, , 39 Cal. Comp. Cas. 56
“However, the employer may lose his right to control medical treatment if he
fails or refuses to provide it. In that event the employee is entitled to procure
treatment for himself with a doctor of his choice and is entitled to
reimbursement for his expenses. ( McCoy v. Industrial Acc. Com., supra, 64
Cal.2d 82, 86.) In McCoy we held that where an employer, albeit in good faith
reliance upon the opinion of its own doctor that further treatment is
unnecessary, refuses to provide it "he has voluntarily terminated his right to
control the course of medical treatment."
How does this work with the requirement that if the injured worker is not
satisfied with the opinion of the treator that the injured worker has to seek a
2nd and third opinion in the MPN then after that to IMR process.
More than a passive willingness
Braewood Convalescent Hospital v. Workers' Comp. Appeals Bd. (Bolton)
(1983) 34 Cal. 3d 159, 161-162 [666 P.2d 14, 193 Cal. Rptr. 157] [48
Cal.Comp.Cases 566 The California Supreme Court has noted that:
“[T]he employer is given initial authority to control the course of the injured
employee's medical care. [citations] Section 4600 requires more than a passive
willingness on the part of the employer to respond to a demand or request for
medical aid. [citation] This section requires some degree of active effort to
bring to the injured employee the necessary relief. [citation] Upon notice of the
injury, the employer must specifically instruct the employee what to do and
whom to see, and if the employer fails or refuses to do so, then he loses the
right to control the employee's medical care and becomes liable for the
reasonable value of self-procured medical treatment. enable him to select a
doctor in any specialty within a reasonable area."
Notice – Unreasonable Offer
“We believe that the WCJ properly excluded the evidence as discussed in his
Report. We observe that even if the other "MPN evidence" was admissible,
defendant merely demonstrated that it may have served notice, but none of the
evidence submitted is evidence that applicant received notice or that lien claimants
received notice. The sole piece of relevant evidence was a letter sent to applicant
about her "treating physician," with no reference to the name of the physician.
(Exhibit G.) Conceivably, the letter could have been a notice to applicant that her
treatment was being transferred from Dr. Dodge. And, there is simply no evidence
in the record in the form of any actual MPN letters, notices or objections that were
sent to any physicians. We agree that lack of notice must result in a neglect or
refusal of treatment but there is no evidence in the record as to that issue, and it
was only raised by defendant in its petition for reconsideration. Moreover, based
on the only evidence in the record, defendant failed to provide evidence that it
appropriately transferred applicant into the MPN.”
MARIA VASQUEZ, vs MARRIOTT INTERNATIONAL; MARRIOTT
CLAIMS SERVICES March 2013 ADJ2976653 (SDO 0363236)OPINION AND
ORDER GRANTING PETITION FOR RECONSIDERATION and DECISION
AFTER RECONSIDERATION
Finding Provider in MPN
Fujihara, a non-MPN physician, to obtain medical treatment. Nearly two years after Dr.
Fujihara released applicant from further treatment, defendant sent its February 6, 2009
letter stating that Dr. Fujihara was not in the MPN implemented by defendant after
applicant's injury, and that "if' his medical treatment was transferred to a provider
within the MPN he would have the right to dispute that transfer decision.' However,
defendant presented no evidence showing that it ever acted to transfer applicant's
treatment from Dr. Fujihara to an MPN physician. Instead, after receiving applicant's
designation of Dr. Lewis as his new primary treating physician, defendant merely sent
applicant the names of 5 physicians it said were in its MPN. However, the unrebutted
evidence showed that none of the physicians identified by defendant in its letter to
applicant and his attorney was reasonably available to serve as applicant's primary
treating physician, and further showed that defendant's web site was unusable.
JOSHUA GROSSMAN vs ARAMARK UNIFORM SERVICE; ACE
RECONSIDERATION AMERICAN INSURANCE Jan 2013 Case No. ADJ2401554
(FRE 023126), OPINION AND ORDER GRANTING PETITION FOR.
RECONSIDERATION AND DECISION AFTER
Defective Notices
The WCJ further found that applicant did not receive
notice of defendant's Medical Provider Network [MPN]
prior to her injury and that a letter sent to applicant on
May 4, 2010 did not comply with MPN notice
requirements. In addition, the WCJ found that defendant's
failure to provide required MPN notices "resulted in a
denial of care." Based upon those findings the WCJ
awarded applicant the cost of treatment outside the MPN
from August 11, 2011 through the date she was
transferred back into the MPN, to be adjusted by the
parties with jurisdiction reserved.
Location
California Code of Regulations, title 8, section
9767.5(b), defendant obligation to provide access to
an MPN within 30 minutes or 15 miles of
applicant's former workplace.
The WCJ concluded that 'workplace' means where
the applicant ispresently regularly employed. The
parties having agreed that said interpretation would
mean the access standards are not met, the WCJ 3
granted the applicant's request to treat outside the
MPN." (Report, p.2.)
Hold Harmless Clause
When a “Order Approving Compromise and
Release”, or any other closing documents has a
“Hold Harmless Clause” stating that the
Applicant (injured worker) is held harmless,
not responsible for any medical bills or liens, it
means that the Defendants has to pay for those
liens”
Make it all about the injured work
not about monies important to show
that treatment was reasonable and
necessary at the same time as
asserting treatment outside MPN
Make sure – one of the most important documents is
to get a copy of the list provider to the injured of
provider within the MPN who will treat - and that
opens several doors and issues including geographic
After MPN
Causation: If stipulated industrial caused state
document that states it
Medical Necessity ; treatment related to
industrial injury – retrospective review if
treatment already provider adjuster has 30 days
Reasonable Reimbursement can use IBR
decisions for same billing code.
Workers Comp: Lesson 5 Medical
Provider Networks (MPN)
www.workcompliens.com
October 06, 2014