Medical Provider Networks are an effort by insurance companies to reduce claims expenses and better manage the care of injured workers in the workers’ compensation system. Injured workers will have to be treated by a doctor within the workers’ compensation medical provider network. Each employer can establish their own MPN, but the network must give injured workers access to medical treatment. The network must have enough doctors to treat common work injuries in all geographic areas of California where an injured worker may live.
Under CCR 9767.5(a), an MPN must have:
- at least three available primary treating physicians to treat common injuries within 30 minutes or fifteen miles of each covered employee’s residence or workplace OR
- specialists within 60 minutes or thirty miles of a covered employee’s residence or workplace.
If these requirements are not met, the injured worker’s remedy usually permits him/her to obtain treatment outside of the MPN. Applicant’s attorneys regularly challenge the validity of MPNs to obtain treatment outside of the MPN.
Applicants wishing to treat outside of the MPN tend to argue there are not three physicians within each specialty who fall within an alternative geographic region. However, in the case of Murillo v. Western National Group, 2021 Cal. Wrk. Comp. P.D. LEXIS 165, the WCAB confirmed if the MPN has at least three primary treating physicians of any specialty within the 15-mile/30-minute radius who is available to undertake the role of PTP, the MPN will have satisfied its obligation to provide medical treatment. In Murillo, the Applicant wanted to treat with a pain management physician as his PTP. Murillo confirmed that an MPN is valid if it meets the 30-mile/60-minute radius for specialists.
If the requirements of the MPN are met pursuant to Murillo and Applicant’s attorney continues to demand treatment outside of the MPN, proceed to request an Expedite Hearing. Remember, the injured worker bears the burden of proving entitlement to treatment outside of an MPN.
Of course, if this criterion is not met, the MPN must permit the injured worker to seek care outside of the MPN. Keep in mind, even a doctor outside of the MPN must follow procedures for workers’ compensation treatment, including treatment requests through Utilization Review and accepting payment through the workers’ compensation insurance carrier.