WCDefenseCA

Hello dear readers!

Your humble blogger bids you a happy Wednesday and hopes that Columbus day saw you enjoying time off rather than scrambling to deny benefits and outwit the vile interpretations of the law that seek to deprive employers of justice and their hard-earned income.

Anywho, I’ve got a good one for you today and it’s about everyone’s favorite topic, Medical Provider Networks.  As well all know, MPNs can be a wonderful tool to provide injured workers with effective care and mitigate costs for defendants.  Employers can craft MPNs with doctors that are determined to see the injured worker treated effectively and returned to productive labor, rather than medicated into numbness and maimed with unnecessary surgery, just to line the pockets of the less-honorable of the applicants’ attorneys and the medical practitioners with more expensive tastes.

The frequent challenge to MPNs has been rooted in a (flawed) interpretation of California Code of Regulations section 9767.5, interpreting subsection (a)(1) to mean that, for an MPN to be valid, a defendant must provide three treating physicians in each specialty within 15 miles of the applicant’s home or workplace.  So if you have 1 chiropractor, 1 physiatrist, and 1 orthopedist within 15 miles of applicant’s home, the theory would go that the MPN is not valid, as you actually need 3 of each.

Well, the recent split panel decision in Luna v. The Home Depot runs contrary to this logic.  Mr. Luna needed an orthopedist to treat his CT, but the MPN only offered 1 orthopedist within 15 miles of his home (even though it boasted 17 within 30 miles of the same).  Applicant argued that the MPN was invalid because defendant’s MPN did not have at least 3 orthopedists within 15 miles of his home to assume the duties of primary treating physician.

The WCJ found for defendant, reasoning that because applicant failed to “produce any evidence indicating that there are not at least three available primary treating physicians within 30 minutes or 15 miles of applicant’s residence or workplace” the MPN is valid.

The WCAB majority agreed – if you want a primary treating physician, the regulations require the defendant to provide you with at least three PTPs of a relevant specialty.  One of each of three different but relevant specialties is sufficient to maintain the validity of the MPN.  By contrast, if applicant wants a specialist, the defendant is entitled to 30 miles or 60 minutes, rather than 15/30.

The string of panel decisions on this topic has been finding the other way, unfortunately, typically invalidating panels if the defense could not provide at least 3 pain management, or 3 chiropractic medicine physicians within 15 miles of the relevant reference point.  But it looks like there is good reason to take this fight up again – the WCAB seems at least to be receptive to this argument.