Happy Monday dear readers!

Your humble blogger is back and hopes you have missed him, as he has sorely missed you.  But, as is custom amongst refined gentlemen of culture and learning, I have returned to you not empty handed but bearing a wonderful gift.  The gift you have been dreaming of since last my blog posts graced your inbox… another blog post.

This one is on Medical Provider Networks and you are going to want to stick around, because it provides some persuasive (sadly, not mandatory) authority regarding the adequacy of MPNs.

So a typical scenario is that applicant’s counsel demands a list of 3 physicians in a particular specialty within 15 miles of applicant’s home ready to take him as a patient.  Often enough, this might be a tall order for an MPN to accommodate, and even when it can, the physicians generally available want to review medical records in advance of the first appointment.

Such was the case in Murillo v. Western National Group.  Applicant’s counsel sent an e-mail to the Medical Access Assistant (MAA), demanding a list of 3 pain management physicians within 30 miles of applicant’s residence.  This, of course, is based on one interpretation of 9767.5(a)(2), which requires at least three physicians within 60 minutes or 30 miles of the employee’s residence or workplace.

The MAA responded shortly thereafter providing a list of.3 physicians in the pain management specialty, but each wanted to review the pertinent medical records before accepting applicant as a patient. 

The parties ultimately proceeded to a hearing, with applicant seeking to be let out of the MPN. 

The WCJ ultimately ruled for the defendant, and applicant sought reconsideration.  On review the WCAB initially acknowledged that the burden of proof is on the applicant in trying to invalidate the MPN.  Further the WCAB relied on Labor Code section 4616 for the proposition that the MPN need only provide an adequate number and type of physicians. 

Summarizing the relevant regulations and Labor Code sections, the WCAB opinion explained that the MPN must provide at least 3 physicians who would be willing to serve as PTPs within 15 miles or 30 minutes of applicant’s residence or workplace.  The only standard for the PTP is to be “competent to treat ‘common injuries experience by injured employees based on the type of occupation or industry in which the employee is engaged, and the geographic area where the employees are employed.” 

The applicant can enlist the assistance of the MAA, but must contact the available PTPs to determine willingness to accept his or her particular medical condition.  That being said “As long as the MPN has at least three primary treating physicians of any specialty within the 15 mile/30 minute access standard who are available to undertake the role of [PTP], the MPN will have satisfied its obligation to provide medical treatment.”  (Emphasis added by your humble blogger).

The WCAB found applicant failed to carry his burden to prove defendant’s MPN was invalid.  The WCAB further rejected the claim that the MPN was invalid because the MAA failed to provide an appointment with a PTP within 20 days, as per California Code of Regulations section 9767.5.  The duty of the MAA is to provide an appointment, within 20 days, for a specialist based on a referral.  Further, since applicant failed to select a PTP, rather than ask for a list of PTPs to choose from, the section further does not apply. 

So, happy result as one could expect – the MPN integrity was sustained!

But keep this panel decision in the back of your minds, dear readers, as it certainly provides guidance on defending the MPN against charges of inadequacy.

Straight on till Wednesday, dear readers!