A Small Caveat to the MPN

It is no secret that I’m a fan of Medical Provider Networks.  A useful tool in California’s Workers’ Compensation defense practice, MPNs save the employer money in medical treatment, filter out junk-science reports, and protect the injured worker from being tricked into adopting a cash-cow posture for less-than-ethical medical practitioners.

Although an employer/insurer can set up an MPN fairly easily, and impose upon the injured worker the duty of using it (if the employee expects the employer to pay for the treatment), there are a few small cracks in the wall.

One such crack can be found in Labor Code § 4616.2, subsection (d)(3)(B).  This exception to the general rules of MPNs allows the current non-MPN treating physician to continue treating the employee for up to 12 months for a “serious chronic condition.”  The determination is initially made by the employer/insurer, and the employee can dispute the determination, first by requesting a report from the treating physician and then by getting a panel QME.

According to section 9767.9(e) of the California Code of Regulations, a chronic condition is one “that persists without full cure or worsens over 90 days and requires ongoing treatment to maintain remission or prevent deterioration.”

In other words, the employer must approve the continuation of treatment for the serious chronic condition, for up to one year, starting on the day that notification is received by the employee.

[Note, as per § 9767.9(f), notice must be sent to the employee and the employee’s treating physician, in English and Spanish, that the employer/insurer has determined that there is not a serious chronic condition and that the employee will be transferred into the MPN.  The regulation also provides that “to the maximum extent possible” layperson’s terms must be used in this notice.]

In other words, dear readers, if you are thinking of adopting an MPN, this is one of the delay tricks doctors and employees will use to stay out of it as long as possible.  This provides them with an additional year to rack up the bill on treatment and produce one report after another.  [Note – under subsection (h), the employer, insurer and employee all have the right to have this matter resolved by going to a panel qualified medical evaluator.]

By no means does this take away from the great value of MPNs – but it is something to be aware of before refusing to pay for an extra year of non-MPN treatment.

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