The Medical Provider Network

Most California employers have an MPN — a network of physicians you generally have to treat within. Workers experience it as being told which doctor they get.

That is not quite what it is, and the difference matters.

Three things to know:

1. An MPN is a list, not a person. After your first visit, you may switch to any other physician in the network without asking permission.

2. If you disagree with your MPN doctor, you get a second opinion, then a third — and then an MPN independent medical review.

3. And if that review agrees with you, you may treat with a physician of your choice — inside or outside the network — and the employer is liable for the cost.

The first 30 days

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.

The form that has to be filed before you are hurt

Labor Code § 4600(d) permits predesignation, and every requirement must be met before the injury:

• You must have health insurance covering non-occupational injuries
• The physician must be your primary care physician who has treated you before
• The physician must agree in advance, and agree to retain your records
• Your employer must be notified in writing before the injury

Chiropractors, acupuncturists, and psychologists cannot be predesignated under this provision.

And employers with an MPN are required to give you the predesignation form and notice at hire or before 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.

Changing doctors inside the network

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.

When you disagree with the MPN doctor

Labor Code §§ 4616.3 and 4616.4 provide an escalating process:

Second opinion. You may obtain a second opinion from another physician within the MPN.

Third opinion. If the dispute continues, a third opinion from another MPN physician.

MPN Independent Medical Review. "If, after the third physician's opinion, the treatment or diagnostic service remains disputed, the injured employee may request an MPN independent medical review."

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.

MPN review is not the same as UR and IMR

These are two different systems and confusing them costs cases.

A utilization review denial is appealed through IMR, not through the MPN process. How UR works and how to check a denial for defects. · How IMR works.

When you can treat outside the MPN

Emergency care — always.

Where the employer did not properly notify you of the MPN. MPN notice obligations are specific, and a defective or missing notice is a recognized basis for treating outside the network.

Where the network cannot actually provide access — no appropriate specialist, no available appointment within the required timeframes, no usable provider list.

Where you validly predesignated.

And after a successful MPN independent medical review, per § 4616.4.

Frequently asked questions

What people actually ask about the network

• They sent me to a doctor an hour and a half away.there are real distance standards, and a network that cannot meet them may not be able to hold you in it
• My doctor won't take workers' comp.common, fixable, and not your fault
• Do I have to go to the company clinic?
• Can I see my own doctor?the answer turns almost entirely on one form you can only file before you get hurt