WCDefenseCA

In an earlier post, I mentioned the Valdez v. Warehouse Demo Services (en banc) case, in which the Workers’ Compensation Appeals Board first ruled that defendants are not responsible for treatment bills originating outside of a validly established Medical Provider Network, before deciding to take more time to consider the issue.

While we are in limbo, waiting to see who foots the bill for extra-MPN charges, a thought comes to mind about the companion arena to the MPN: what about the Pharmacy Benefit Networks established pursuant to Labor Code § 4600.2?

In the case of Brambila v. Vons, Inc. (2010), the WCAB denied a lien-claimants petition for reconsideration of the Workers’ Compensation Judge’s ruling that liens asserted by extra-PBN suppliers of drugs are not valid or enforceable.  The WCAB denied reconsideration, relying on § 4600.2.

(As an aside, I have had lien-claimant argue that because the injured worker didn’t understand the PBN network notices, the PBN does not apply to the worker and he or she can obtain drugs wherever he or she wants.  But even if the worker doesn’t understand the plain meaning of the notice, the pharmacist does, and the meaning of the objection letters that followed the first filled prescription as well.)

Since the WCAB now needs more time to consider whether or not insurance companies and self-insured employers are liable for extra-MPN treatment, is it possible that the same reasoning applies to extra-PBN dosages.  The Valdez case is newer and en banc, giving it controlling power over Brambila.

Until the Valdez decision comes out, Brambila is still good law.  If lien-claimants demand payment of extra-PBN liens, settle for token amounts or rush to trial before the WCAB changes its mind in Valdez!

In April of 2011, the Workers’ Compensation Appeals Board issued a firm rebuke to applicants’ attorneys and lien claimants all over the state:  “where unauthorized treatment is obtained outside a validly established and properly noticed MPN, reports from the non-MPN doctors are inadmissible, and therefore may not be relied upon, and … defendant is not liable for the cost of the non-MPN reports.”  (Valdez v. Warehouse Demo Services).

The advantages of setting up a Medical Provider Network are many, some of which are discussed here.  In particular, under Labor Code § 4616 insurers and self-insured employers can set up networks of medical providers, and all treatment must be received from one of the providers in the network.

In Valdez, applicant was provided treatment within the insurer’s MPN for an admitted injury.  After a month of such treatment, applicant began receiving treatment from a doctor outside of the insurer’s MPN at the behest of her attorney.  Apparently this was because the MPN doctor’s treatments were not helping her, yet she never contacted the insurer to find a different doctor within the MPN.

The WCJ awarded additional temporary disability, relying on the report of the non-MPN doctor.  The WCJ further allowed a lien from the Employment Development Department for the TD period.

In response to defendant’s petition for reconsideration, the WCAB held that the law was the law, and absent a situation in which defendant refuses to provide medical treatment “that is reasonably required to cure or relieve the injured worker from the effects of his or her injury”, the MPN stands.

But then the WCAB blinked, and now we have the NEW Valdez opinion.  On July 14, the WCAB issued a new en banc opinion, calling for more time to study the issues of the Valdez case.  Hopefully the new opinion will not “fix” what isn’t broken.

As soon as your humble blogger knows more, so shall you.  In the meantime, I would hope for the best.