WCDefenseCA

Hello dear readers!

Your humble blogger wishes you a happy Wednesday.   Today’s post is not about lien claims, even though every other news source is covering this happy news in-depth – the injunction is lifted and un-activated lien claims are to be dismissed as of January 1, 2016.

Today’s post is about everyone’s favorite topic: Medical Provider Networks!  We are faced, once more, with the same question: Would a rose by any other name smell as sweet? Can a doctor listed in an MPN treat at a non-MPN location and still be considered the PTP?

This issue came up in the writ denied case of Pasquel v. Boeing Company.  Applicant selected a PTP from defendant’s MPN, and then the PTP started treating applicant at a non-MPN location.  Is this ok with you, dear readers?

The WCJ found that applicant was entitled to treat with his doctor at any location, and so awarded costs for services rendered.  Defendant sought reconsideration, reasoning that the MPN is the MPN, and non-MPN locations should be excluded from reimbursement.  The WCAB majority ruled “[w]e rejected defendant’s contention that the inclusion of [the PTP] as a participating provider at U.S. Healthworks precludes applicant form selecting him as his treating physician to provide medical treatment at a different medical office.”

The majority reasoned that when there was no specific notice that the PTP was authorized only at the listed location, there was no limitation to treating with that PTP at a non-MPN location, “as there is no statutory requirement that medical treatment be provided at a listed location.”

Reading the opinion and dissent, your humble blogger is a bit puzzled… what am I missing?  We have regulations, don’t we?  In fact, section 9767.3(c)(4) is pretty clear: “An MPN determines which locations are approved for physicians to provide treatment under the MPN.  Approved locations are listed in an MPN’s provider listing…”

It does not appear that section 9767.3(c)(4) was discussed by the panel opinion, at least based on the Lexis summary.  But, even though it is a lowly regulation, and does not rise to the prominence of a statute, we still have regulatory authority that seems to be directly on point: the MPN gets to pick the doctors and the locations.  Your MPN doctor isn’t allowed to lure you from the U.S. Healthworks clinic to his van down by the river with a trail of pain meds…

In any case, dear readers, if applicant is treating with an MPN physician at a non-MPN location, don’t sit back and rest, thinking that bill will never be due.  You paid for your MPN, now defend it! Under Labor Code section 5502(b)(2) expressly allows you to set the issue of whether an applicant must treat within the MPN for an expedited hearing, and your defense attorneys are more than happy to be tasked with the work.

Weekends’ a comin, dear readers, chins up!