How California’s Medical Provider Network (MPN) Works
After a workplace injury, getting appropriate medical treatment is the first and most important part of a California workers’ compensation claim. However, injured employees do not always have the same freedom to choose a doctor that they would have with ordinary health insurance. If your employer or its workers’ compensation insurer uses a Medical Provider Network (MPN), you will generally receive treatment from doctors and other providers within that network.
Understanding how California’s workers’ compensation MPN system works can help you make informed decisions about your medical care and avoid problems with your claim. At Invictus Law, P.C., our Southern California workers’ compensation lawyers represent injured workers throughout Orange County and the Inland Empire, helping clients protect their rights when medical treatment becomes a source of disagreement with an employer or insurance company.
What Is a California Workers’ Compensation MPN?
A Medical Provider Network is a group of healthcare providers established by a workers’ compensation insurer, self-insured employer, or other authorized entity to treat employees who suffer work-related injuries or illnesses. The MPN must be approved by California’s Division of Workers’ Compensation (DWC).
An MPN includes physicians who treat occupational injuries as well as doctors with expertise in different areas of medicine. The network must also meet California’s requirements for access to medical care and follow applicable workers’ compensation treatment guidelines.
Not every California employer is required to use an MPN. However, when an employer or insurer has an approved and properly implemented MPN, injured employees receive their workers’ compensation medical care through that network, subject to certain exceptions.
How Do I Know Whether My Employer Has an MPN?
Your employer or the workers’ compensation claims administrator should provide information about the MPN if you are covered by one. This information should explain how to access the network and locate participating doctors.
You should receive information about how to access the MPN provider directory. California regulations require covered employees to have access to a regional listing of MPN providers as well as the complete provider directory through the MPN website or in writing.
If you are unsure whether your employer uses an MPN, ask your employer or claims administrator for the MPN information before making appointments for non-emergency treatment. You can also ask for assistance locating an appropriate provider.
Who Treats You After a Workplace Injury?
When you report a work injury, the employer or insurer arranges an initial medical evaluation with an MPN physician if an MPN applies to your claim. California regulations require the claims administrator to arrange this initial evaluation and provide treatment consistent with applicable workers’ compensation requirements.
After your first examination, you generally have the right to choose another doctor within the MPN. You do not necessarily have to continue seeing the first physician selected for you if you are dissatisfied with the treatment or want another provider within the network.
This ability to change doctors can be particularly important when you have concerns about your diagnosis, treatment plan, communication with your physician, or the provider’s understanding of your particular injury.
Can I Choose My Own Doctor?
Whether you can treat with your personal physician instead of an MPN doctor depends on the circumstances.
One important exception involves predesignation of a personal physician. If you properly predesignated your personal physician or medical group before the injury occurred, you may be able to receive treatment from that doctor after suffering a workplace injury rather than being required to use the employer’s MPN.
Predesignation has specific requirements, so simply having a regular doctor does not necessarily mean that you can use that physician for a work injury.
If you did not properly predesignate a personal physician and your employer has an applicable MPN, you will need to select your treating providers from the network.
What If I Disagree With My Doctor?
An injured worker does not have to accept a diagnosis or treatment plan without question. California’s MPN rules provide a process for obtaining additional medical opinions when you disagree with your treating physician’s diagnosis or recommended treatment.
You can request a second opinion from another physician within the MPN. If you continue to disagree with the diagnosis or treatment after the second opinion, you can request a third opinion from another MPN physician.
Important procedural requirements are associated with this process. For example, when requesting a third opinion, the injured worker must make the appointment within 60 days after receiving the list of available physicians. Missing the applicable deadline can result in losing the right to use that particular third-opinion process for the disputed diagnosis or treatment.
If you still disagree after the third opinion, you may be able to request an MPN Independent Medical Review (IMR) through the DWC.
What If the MPN Does Not Have the Doctor I Need?
California’s MPN rules include access standards designed to ensure injured workers can obtain appropriate medical treatment. For example, MPNs must maintain access to physicians and specialists and meet specified appointment-time requirements.
If an MPN does not have an appropriate physician to provide recommended treatment, there are circumstances in which an injured worker may be permitted to receive treatment from a physician outside the MPN within a reasonable geographic area.
This is one reason it is important to communicate with the claims administrator and document problems obtaining appropriate care rather than simply going outside the network on your own.
What Happens If I Go to a Doctor Outside the MPN?
If you are required to treat within an MPN and see an outside doctor without authorization or without falling within an applicable exception, you could encounter problems getting the treatment paid for through workers’ compensation.
Before scheduling non-emergency treatment outside the MPN, determine whether you have the right to do so. Depending on the circumstances, you may have options for changing doctors within the network, obtaining additional opinions, or challenging the network’s ability to provide appropriate treatment.
If the insurance company refuses to authorize necessary care or you believe the MPN is not following California requirements, an attorney can help you determine what options may be available.
What If the Insurance Company Denies My Treatment?
Being treated through an MPN does not mean every requested treatment is automatically approved. Medical treatment requests can still be subject to California’s utilization review requirements and applicable treatment guidelines.
If treatment is denied or modified, there may be additional procedures for challenging that decision. The MPN second- and third-opinion process applies to disputes over diagnosis or treatment prescribed by an MPN physician, while other treatment disputes may involve the separate utilization review and independent medical review systems.
Because these processes have different requirements and deadlines, it is important to understand exactly why treatment was denied before deciding how to challenge the decision.
How Invictus Law, P.C. Can Help
Medical treatment is often one of the most complicated parts of a workers’ compensation claim. An injured worker may be dealing with an MPN, changing doctors, disputed diagnoses, treatment denials, or questions about whether a particular provider is authorized to treat the work injury.
At Invictus Law, P.C., we help injured workers throughout Orange County and the Inland Empire understand their rights and navigate disputes involving medical treatment and workers’ compensation benefits. Our attorneys can review the circumstances surrounding your claim, help identify problems with the handling of your medical care, and advocate for the benefits you are entitled to receive.
Contact Invictus Law, P.C. About Your Workers’ Compensation Claim
Your medical care can have a direct impact on your recovery and the outcome of your workers’ compensation claim. If you are having trouble finding an MPN doctor, disagree with your diagnosis or treatment, or believe your workers’ compensation insurer is improperly restricting your medical care, do not ignore the problem.
Invictus Law, P.C. represents injured workers throughout Orange County and the Inland Empire from our offices in Orange and Ontario. Contact us today for a free consultation to discuss your workers’ compensation claim and learn how we can help protect your rights.
