Understanding the complexities of Medical Provider Networks (MPNs) in the state of California Worker’s Compensation System

January 4, 2024

The establishment of Medical Provider Networks (MPNs) in the California Workers’ Compensation system was intended to streamline medical care and control costs. However, concerns and criticisms have arisen, particularly from injured workers and the applicant workers comp lawyers in Los Angeles who represent them.

The primary concern centers on the limited choice of healthcare providers within MPNs, which raises questions about the quality of care, potential biases, and conflicts of interest. While regulatory safeguards such as Medical Access Assistants (MAAs), Independent Medical Review (IMR), and access to second opinions are in place to address some of these concerns, challenges persist. 

The ongoing debate surrounding MPNs underscores the importance of a balanced approach that ensures injured workers receive prompt and impartial medical care while maintaining cost controls within the California Workers’ Compensation system. Ultimately, the goal should be to prioritize the health and well-being of injured workers, facilitating their recovery and return to the workforce.

What are MPNs in California Workers’ Compensation?

Medical Provider Networks (MPNs) are networks carefully comprised of healthcare providers that are pre-approved to offer and provide medical treatment to injured workers within the California Workers’ Compensation system. In summary, they act as a managed care system for work-related injuries, aiming to allegedly streamline medical treatment and control costs.

The Intended Purpose

The number one goal of MPNs is to provide injured workers in the state of California Worker’s Compensation system with prompt and efficient access to medical care. MPNs are designed to direct injured workers to specific healthcare providers, that are chosen by the insurance companies, with no input from the applicant attorneys or the injured workers within the network.

The reasoning behind this was to expedite treatment and minimize disputes over medical care. Unfortunately, this intent has been abused by insurance companies to create a maze of larger MPNs splintered into smaller MPNs, making it more difficult to get doctors who would advocate for the injured workers on these networks.

Concerns Raised by Injured Workers and Applicant Attorneys

Despite their intended purpose, MPNs have sparked controversy and very legitimate concerns, particularly among injured workers and the applicant attorneys who represent them.

Limited Choice of Providers

One of the most significant criticisms of MPNs is that they limit the choice of healthcare providers for injured workers. Instead of selecting a physician of their choice, injured workers are often required to seek treatment within the network. This limitation can raise several concerns:

Quality of Care

Injured workers may question whether healthcare providers within MPNs prioritize their best interests or cost containment. This perception can lead to doubts about the quality of care they receive. Applicant attorneys in the state of California contend that, due to the fact that the MPNs are established by the insurance companies who select their own doctors, injured workers are not getting a fair and subjective opinion on their condition or medical treatment.

Lack of Personal Connection

Injured workers may have established relationships with specific doctors, and being forced to see a new physician can disrupt the continuity of care. In the majority of states, MPNs do not exist for this exact reason. Applicant attorneys and injured workers in the state of California believe that, by creating an MPN that is customized to the rules and regulations set forth by the insurance company, the subjectivity and integrity vanish which places them at a huge disadvantage.

Potential for Bias

There is concern that physicians within MPNs may feel pressure to prioritize cost savings over providing comprehensive care, potentially influencing their medical decisions. Several applicant attorneys have proven that there is an abuse of bias. 

Doctors, specifically agreed and qualified medical evaluators, have been subjected to deposition by the applicant attorneys representing the injured workers. In the process of these depositions, facts have come out proving that doctors are operating with extreme bias. This is fueled by the doctors’ fear of being thrown off the MPN and losing income which, inadvertently, results in subpar and even inadequate medical care for the injured worker.

Difficulty Changing Physicians

Even when injured workers are not satisfied with the care they receive within an MPN, changing physicians can be a challenging process. This difficulty in switching providers can lead to continued dissatisfaction with medical treatment.

Inadequate Access to Specialists

Some injured workers may require specialized medical care due to the nature of their injuries. In MPNs, access to specialists may be limited, causing delays in receiving necessary treatment and potential complications in the recovery process. 

This has proven to be an extremely problematic issue since highly specialized doctors are in such demand. They are unwilling to operate and treat the patients with an extreme bias that the insurance company expects from them. As a result, there is a shortage of these types of doctors on all medical provider networks. 

The good news is that there is a law in the California Worker’s Compensation system that states that, if there are no free specialists within 30 miles of the address of the injured worker, the applicant attorney can go outside the MPN and choose any doctor. This has proved to be a very helpful provision in getting injured workers fair, objectively timely, and efficient medical care.

Perception of Conflicts of Interest

Applicant attorneys often raise concerns about perceived conflicts of interest within MPNs. They argue that the close relationship between insurers and the medical providers in the network can lead to doubts about the impartiality of medical care decisions. 

This perception is more than just a perception. It’s an actual fact. In order for a doctor to be listed on a medical provider network for a Worker’s Compensation carrier, they must sign a contract. 

In that contract, they are essentially handcuffed from doing their job with integrity and respect to unbiased medical opinions and medical care for injured workers. This is a very troublesome issue and many applicant attorneys are arguing that patients are losing the right to due process.

Impact on Legal Representation

Applicant attorneys also assert that the limitations imposed by MPNs can complicate legal representation. When medical care decisions are influenced by the network’s interests, attorneys may face additional challenges in advocating for the best interests of their clients.

This impact is very real and very troublesome. California in 2023 essentially has a very serious problem with almost all doctors having to acquiesce to the MPN standards, which are not fair or equitable towards injured workers.

Regulatory Safeguards in MPNs

To address some of these concerns, regulatory safeguards have been implemented within MPNs. However, some of these safeguards are nowhere near as powerful and effective as they need to be to prevent insurance companies from continuing to “stack the deck” against injured workers in the state of California.

Medical Access Assistants (MAAs)

MAAs are individuals within MPNs who help injured workers navigate the system and facilitate communication between the injured worker and the healthcare provider, typically assisting in scheduling appointments and addressing concerns. 

The problem with MAAs is, again, that they are not impartial third parties. They work for insurance companies and, while they do help injured workers navigate the process, the injured worker is still stuck in an MPN that is lacking objectivity with doctors who have compromised integrity.

Independent Medical Review (IMR)

IMR is a dispute resolution process in California Workers’ Compensation that allows injured workers to seek an independent review of medical treatment decisions. If a dispute arises over recommended treatment, an independent physician can be summoned to evaluate the case. 

Independent medical review has proven to be a total disaster in the eyes of both the injured workers and applicant attorneys, mainly because IMR is a process where doctors reviewing the case never come into contact with the injured worker.

In other words, if a medical professional, specifically a treating physician or specialist, requests surgery or some other type of medical procedure, the IMR personnel performs no examination or meets with the patient face-to-face.

They are making determinations based solely on medical records, leading applicant attorneys to believe their opinions are strongly skewed to benefit the insurance companies, rather than injured workers.

Access to a Second Opinion

Injured workers within MPNs generally have the right to seek a second opinion from a physician outside of the network, which can provide an alternative perspective on their medical condition and treatment options. 

Second opinions are very valuable when it comes to helping an injured worker get a less biased point of view from a specialist. The problem here is that a second opinion can only come from a doctor inside the medical provider network.

Needless to say, this creates the same exact issue: dealing with a biased doctor whose priority is to not get thrown off a medical provider network just for advocating properly for an injured worker.

Conclusion

In the beginning, medical provider networks sounded like a good idea that could’ve had a positive impact on the workers’ comp system, injured workers, and employers – if they had left them open to all qualified doctors. Unfortunately, that is not the case, as doctors remain bound by contracts with the insurance companies, making them beholden to their wishes and agenda.

If a doctor does not follow the direction of the MPN, which is written in a way that grossly gives the insurance company an advantage over the injured worker, they risk being thrown off the network and losing their income.

This blatant abuse and intimidation forces doctors to not only advocate for insurance companies but to also act without integrity or regard for injured workers’ well-being. This is why both applicant attorneys and their clients are heavily against MPNs and resolutely call for their dissolution.

Who’s the leading workers’ comp lawyer near me in Los Angeles?

If you feel that you’re not getting adequate medical help through MPN or need assistance protecting your legal rights, turn to ethical and aggressive attorneys at LA Accident Pros. Our team has extensive experience handling various aspects of work comp claims and intimate knowledge of the Los Angeles legal scene, making us uniquely qualified to aid you in your fight for justice. Get in touch with us today for a free consultation and discover how some of the most well-versed attorneys in the South Bay area can ensure your rights are protected.