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Access to MPN Care - Anecdotes

  • State: California
  • - Popular with: Legal
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The following discussion was recently held in the California Professional Work Comp Forums http://www.workcompforums.com/ca/pro/messageview.cfm?catid=19&threadid=2542. It has been reproduced here, edited for grammar, spelling and succinctness, as the editors felt this discussion and ultimate resolution important given the current debate in the community regarding access to medical care:

Q: Here is an oft-occurring scenario in my location:

1. Pt. gets told they must transfer to MPN care & are given a list of MPN doctor's in our area.
2. With one of the largest WC networks, there are only 3 MPN doctors on their list for our area: 2 of whom are out of practice and the other has moved out of the area (their list is approximately 8 years out of date). So, effectively, they have no MPN coverage in this location, OR
If the MPN is one of the large health insurance PPN's, the pt. is given a list of 10-12 names, calls each one and is told the doctor does not accept WC pts. Again, there is effectively no MPN coverage.

Now what? Pt's. non-MPN doctor won't continue treating because they've been told they won't be paid. AA's do not seem to understand the problem, or even that the IC has an obligation to provide care. Today, I spoke with a local AA on behalf of a pt. in the midst of the second scenario above and he said all the pt. has to do is go to an MPN doctor (with a minimum travel time of 2 hours each way) and then the MPN doctor can refer the pt. out-of-network to a local doctor. Huh? I seriously doubt that's going to fly.

What do these in-limbo pts. do? Who do we get the word to that these MPN's are not fulfilling their geographical coverage obligations?

A1: Check out CCR 9767.5(a) and (b).

The AA you were speaking with should retire. It will probably take an unrepped IW to challenge the geographical "access standards." I would file a complaint (certified, return-receipt -- as always) with the acting AD seeking invalidation of the MPN, then seek an expedited hearing on the need for treatment to be provided within a reasonable distance from the workplace, or from the IW's home, as mandated by CCR 9767.5(b).

A2: I have had clients of my firm call all 20 doctors in Fresno which are on an MPN with a local carrier, only to be told:

1. We don't "do" w/c;

2. We aren't in that group any more, haven't been for 5 years;

3. We aren't taking new patients;

4. We can't give you an appointment for 3-4 months!

Yes, these cases will be litigated, but even emergency, "expedited" hearings now take 4 months or so...do the math! Encourage patients to contact

Hopefully, in the near future, MPNs will be "voided" who include docs who did not agree to be members, same with those not taking w/c claims or not taking new patients, or those not able to see the patient for more than 30 days in the future.

The system we currently have encourages outright misrepresentation by defendants who don't care whether the docs they list on their MPN ever see or treat patients or not...they just want to get patients away from their current treaters who cost them more money.

To my way of thinking, to list doctors on an MPN who can be contacted by EEs for care who refuse to treat injured workers is misrepresentation and sanctionable. The same goes for those who can't see patients in a reasonable timeframe.

The natural "penalty" should be that the EE gets to select a physician of choice if, i.e., 1 or 2 or 3 of the proposed MPN physicians will not seem them within 30 days. If that were a requirement, the MPN lists would very shortly be cleaned up...or become dead letters!

A3: My experience:

1. Defense sends M.P.N letter.

2. Mostly M.P.N Doctors say no on new business.

3. I Pick an M.P.N Doctor. It usually takes 3 different Doctor selections to get an M.P.N Doctor who will actually set and exam.

3. The exam is set sometimes 30 to 60 days out.

4. Applicant finally gets M.P.N Dr. exam. Absent need for immediate surgery, Applicant gets minor care (basically pills) then P&S with little if any P.D or future medical care.

5. I Object to P&S report and go Q.M.E route.

6. In the interim Applicant still needs medical care. Some Applicants cannot work because their medical condition is not fixed.

A4: The problem is always the same as an AA. The time needed to correct this situation versus the cost to AA given the new PD schedules (i.e. can he/she make a profit pursuing these matters and keep their doors open)

If that is not an issue, several options apply. 1 Expedite the treatment recommended by the non-MPN as L.C. 4600 requirements are separate from the MPN. If an EE fell 20' from a roof and broke his leg, do we need to hear from a MPN doctor that the setting of the leg is reasonable and necessary or would not a non-MPN doctor have the same conclusion. In short, treatment is reasonable and necessary as determined by the medical facts, not by whether the doctor is in the MPN or not. At the hearing be prepared to put on evidence of the EE's attempts to get treatment and evidence that the doctors provided do not provide WC txmt, etc. I believe this is sufficient to get you outside of the MPN. I would argue that a list of doctors that is reasonable in geographic location, but who do not accept WC txmt cases is no MPN at all and there really is not a MPN doctor in the area. Therefore, the carrier has failed to provide an MPN doctor and the applciant can choose a doctor outside of the MPN. 2 If really aggressive, ask the WCJ (and you can to) report the failure to have an adequate MPN to the WCAB/DIR to challenge the validity of the MPN network application filed by the carrier with the WCAB/DIR. Probably will not make any difference, but if enough people do it the problem may finally be addressed.

A5: I spent three hours one day making about 60 phone calls only to be told NO by every doc on the four lists that the CE sent to me for a patient. The patient's AA finally filed for a hearing citing the IC was causing unnecessary delays in care by demanding the referral be sent to an MPN doc on their list. The patient won, now granted it took months to get to that point, but it is a step that worked. The last time, same pt btw, needed a referral out, the CE gave me another list. After about 20 calls I called and explained the problem. She was kind enough to give auth for the initial visit with the doc of our choice, and helped me located someone for the patient within the network a few weeks later. That too is a great start. Just a thought, that's all.

A6: You should report provider access problems to the MPN itself. Under 9767.12 (a) (7) each MPN must have a process to assist covered employees who are having trouble finding a physician or getting an appointment. You can also report access problems to DWC which has oversight of the MPNs' ongoing obligations to meet their approval standards.

MPN complaints may be sent to Kathy Dervin at kdervin@dwc.ca.gov. Please put "MPN complaint" in the subject line. The minimum information we need to follow-up on complaints is:
Name of MPN (or payer)
Name of injured employee, claim number, employer
A description of the problem and any efforts that have been made to date to solve problem
If there is an attorney representing the IW (name and ph number or email)
Contact info for person making complaint (email, phone).

We plan to post a MPN Complaint form on our website (DWC) sometime in the near future.

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The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.

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