MPNs Must Include Chiropractors!
It is no secret at all that your tireless and consistent blogger is a fan of Medical Provider Networks. He has screamed his approval from the mountaintop of this blog for all to hear. But, realistically, the MPN is not a panacea: every armor has weak points.
One such gap in the defense was touched on in the recent case of Garcia v. Zenith Insurance Company (2011) 39 CWCR 293. There, a Workers’ Compensation Judge had awarded applicant treatment outside of the MPN because the MPN did not include chiropractors. Citing California Code of Regulations 9767.5, the WCJ let the applicant proceed with a non-MPN chiropractor.
The WCAB denied defendant’s petition for reconsideration.
Are you using an MPN? Does it have “at least three physicians of each specialty…”? Are there physicians within “60 minutes or 30 miles” of where your employees live or work? These are all questions to ask, and regularly — the MPN is not a magic want but a scalpel to be used to great effect but only when wielded with precision and skill.
In any case, the good people at Zenith are no doubt working on their MPN right now, looking for honest chiropractors to add to their lists.
Your humble blogger wishes you a happy new year – enjoy the revelry and stay safe. I will be at your service, bright and early, on Tuesday, January 3rd, 2012. See you next year!
Greg,
The requirement to include Chiropractors is actually found in Labor Code Section 4616 (a) (1), which reads in relevant part, “…The provider network shall include an adequate number
and type of physicians, as described in Section 3209.3, or other providers, as described in Section 3209.5, to treat common injuries experienced 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 fundamental requirement is that an MPN must include all physicians as defined by the Labor Code.
Most disturbing this situation points out another fundamental weakness of MPNs. How did this MPN get approved in the first place?
MPN certifications can apparently fall out of compliance with no oversight. To make certification easier for employers, Labor Code 4616 allows MPN applications to be approved automatically after 60 days if the DWC doesn’t timely review them. Apparently, this MPN application was not reviewed; Or if it was, it was either approved incorrectly OR it originally contained DCs. If the latter is the case, then when the DCs were dropped, a material modification should have been submitted for approval – at which point, the DWC shouldn’t have approved the material modification due to the obvious deficiency – unless the DWC let 60 days lapse (again) and never looked at it.
Regardless of how it got there, this MPN is a poster child for what can go wrong. Two additional questions arise: (1) How many more of the 1500+ MPNs contain similar deficiencies and (2) Why does the DWC have to wait to hear from the WCAB before taking action to follow its de-certification process?
Thank you for drawing attention to this situation.
Steve:
Excellent comment. I think there is a healthy balance here. On the one hand, a self-insured employer or an insurer can have an MPN without being stalled by DWC inaction. On the other hand, when the MPN falls out of bounds or doesn’t meet the statutory and regulatory requirements, a WCJ will let the applicant seek treatment outside of the MPN.
Thank you for all this great information. I am a chiropractor practicing in the LA area and recently had several returning patients that got injured on the job. Being slightly new to the WC world I had to contact the Insurance company who luckly confirmed my MPN participation. I guess some of them are using regular insurance participating paroviders list.
I ttreated the patients and released her back to work within 20 visits, sent my reports and bills and got compensated for my services. I was then thinking , Great let me see which other MPN I am listed on. Little did I know that itis almost impossible to get on any of the MPN lists. I am an honest chiropractor who just want to treat patients and get paid for my services. I will try Zenith. Thank you for the information. Any other ideas or information will be greatly appreciated.