The Medical Provider Network — choosing and changing your doctor

If you did not predesignate a personal physician before the injury, the employer controls your medical care for the first 30 days after you report it. After that you may change — but if there is an MPN, you change to someone inside it. If you did predesignate, you go to your own doctor.

• You must have health insurance covering non-occupational injuries — A § 4600(d) requirement.
• The physician must be your primary care physician who has treated you before — Not a new doctor chosen for the purpose.
• The physician must have treated you before, keep your medical records, and agree in advance to be predesignated — Their agreement is part of the predesignation.
• Your employer must be notified in writing before the injury — Every requirement must be met before the injury.
• Chiropractors, acupuncturists, and psychologists cannot be predesignated — Under this provision.

Every employer is required to give you the predesignation form and notice at hire or by the end of your first pay period. Most workers never see it. If you are reading this and you are not currently injured: predesignate today. It is ten minutes, and it is worthless afterward.

You may change treating physicians within the MPN after the first visit, and you do not need anyone’s approval. This is the most under-used right in the treatment process.

The employer must give you access to the MPN provider list, and it must be current. If you cannot get a usable list, say so in writing — a network that cannot produce accessible, available providers has a problem. And you may request a specialist within the network appropriate to your injury.

Labor Code §§ 4616.3 and 4616.4 provide an escalating process: a second opinion from another physician within the MPN; if the dispute continues, a third opinion from another MPN physician; and then, “if, after the third physician’s opinion, the treatment or diagnostic service remains disputed, the injured employee may request an MPN independent medical reviewIMR Independent Medical Review. The appeal from a UR denial. 30 days (10 if the dispute is only over drugs on the MTUS Drug List)..”

How: a one-page “MPN Independent Medical Review Application” provided by the administrative director, with a signed release for medical records. Timing: findings within 30 days of the examination. And where the reviewer certifies in writing that an imminent and serious threat to health may exist, the report is expedited and rendered within three days.

THE PART THAT MATTERS MOST — § 4616.4

Where the reviewer determines the disputed treatment is consistent with the regulations, “the injured employee may seek the disputed treatment or diagnostic service from a physician of his or her choice from within or outside the medical provider network,” and “the employer shall be liable for the cost.”

That is the exit. A worker who works the process and wins is no longer confined to the network for that treatment — and the employer pays.

These are two different systems and confusing them costs cases.

A utilization reviewUR Utilization Review. The process that approves, modifies, or denies each treatment request. A modification is a denial of what it left out. denial is appealed through IMR, not through the MPN process.

How UR works, and how to check a denial How IMR works