Suffering an injury on the job is difficult enough, but for workers in California, receiving treatment means dealing with extra layers of confusing bureaucracy. Instead of being able to use your own primary care physician, state law requires injured workers to seek treatment through a closed system known as a medical provider network (MPN). These networks not only give more control to insurance carriers, but research indicates that in over 60% of cases, MPN providers either refused or delayed treating injured workers.
Despite their drawbacks, workers must follow the CA MPN rules to get their care covered. For a claim to be successful, it’s essential to understand the MPN process, all relevant legal rights, and the important role an attorney can play in protecting your benefits.
What is a Medical Provider Network (MPN)?
According to the California Department of Industrial Relations, a medical provider network (MPN) is a specific group of doctors and medical providers set up by an insurance company or self-insured employer. This network, which must be approved by the Division of Workers’ Compensation (DWC) administrative director, is used to treat employees who get injured on the job.
Unlike a typical PPO health plan, which offers some flexibility, a workers’ comp MPN functions more like an HMO. The networks are “closed”, meaning the insurance company will only pay for treatment from doctors inside that specific group, and your choices are limited to the providers the MPN has approved.
While the California legislature established the MPN system in 2005, it is the insurance carriers who create, manage, and control their own individual networks. The carrier hand-picks the doctors included in their directory, who are often employed by industrial clinics rather than private medical practitioners (which can create conflicts of interest). Selecting a doctor from this pre-approved directory is one part of the multi-step process you must follow in order to receive care.
How the MPN Process Works: 5 Steps to Get Treatment as an Injured Worker in California
While the exact procedures can depend on your employer and unique situation, getting medical care through an MPN typically follows a five-step process:
- Get the MPN provider list: The Division of Workers’ Compensation (DWC) states that workers are entitled to a complete directory of providers, which must be obtained from the insurance company. This directory can come in the form of a website URL or a written regional list upon request.
- Select the type of doctor needed: Workers will then select what kind of doctor they need from the list. For example, if someone suffered a back injury, they may need to select an orthopedist, while a head injury could instead require a neurologist.
- Find an available doctor: After determining their needs, workers will need to call doctors in that specialty until they find one who is both willing and able to treat them.
- Notify the insurance carrier: Once a doctor is found, workers must inform the insurance carrier of their chosen provider.
- Wait for authorization: The claims adjuster must send a written authorization and the worker’s medical records to the doctor before treatment can begin.
Following this process is mandatory. If an injured worker goes outside the network for care or does not get the required authorization, the insurance company is not obligated to pay for the medical treatment. Even when followed correctly, this rigid set of procedures is only one of several barriers that workers will face during the MPN process.
Common Barriers to Care in the MPN System
The DWC has rules for MPNs and requires them to meet certain access-to-care standards. However, injured workers still frequently face significant barriers to getting proper care. Common problems include:
- Unreliable Provider Lists: While DWC access-to-care standards require a minimum of three physicians available for each commonly used specialty, many MPN provider lists are unreliable or out-of-date. This can make identifying an available physician difficult. Even if a list is updated, workers often struggle to find a doctor located within a reasonable distance or one able to accept new patients.
- Delays and Denials: Workers experience long waits for appointments or, more commonly, delays from the claims adjuster in authorizing their choice of doctor. These refusals and delays can stall a worker’s medical recovery and harm their claim.
- Quality of Care: Insurers often fill their networks with clinics that specialize in occupational medicine. These clinics frequently rely on insurer contracts for their business, which can create a conflict of interest. Doctors at industrial clinics may feel pressured to prioritize cost containment over a worker’s need for comprehensive care, or they risk being removed from the network. As a result, many injured workers feel they are not able to obtain the best quality of medical care available to them.
These systemic problems can leave an injured worker without timely treatment and with little control over their recovery. The law, however, does provide several ways to regain some of that control.
California Workers’ Comp Medical Rights: Changing Doctors, Second Opinions, and the IMR Process
While the MPN system is restrictive, it is not absolute. California law provides injured workers with several specific rights to manage their medical care, dispute a doctor’s findings, and in some cases, avoid the network completely.
- The Right to Pre-Designate: An employee may be able to legally receive treatment outside an MPN through a process called pre-designation. As long as employees pre-designate a physician before an injury occurs, they are exempt from the MPN process. To be valid, the employee must have health insurance for non-work-related injuries (such as a personal PPO or HMO). The doctor must also be their regular physician and agree in writing to treat them for work injuries. This written notice must be given to employers before an injury occurs.
- Changing Doctors Within the MPN: For workers already in the MPN, the DWC indicates that employees can choose another provider in the network after their first visit. However, the process for changing doctors is the same as the initial process: the worker will get a new list of at least three physicians in that specialty, and once again, they will have to find one who fits their case.
- Getting a Second or Third Opinion: If an injured worker disagrees with their MPN doctor’s diagnosis or treatment plan, they have the right to request a second and third opinion from other doctors within the same MPN.
- The MPN Independent Medical Review (IMR): If the disagreement continues after the third opinion, the worker has a final option. The DWC allows injured workers to request an MPN independent medical review (MPN IMR). During this process, a neutral doctor from outside the MPN will review the case to resolve the medical dispute.
While these rights exist on paper, the challenge is putting them into practice. The system is complex, and Insurance carriers have little incentive to make the process easier. In order to handle complicated procedures like proving pre-designation validity or navigating an independent medical review, workers need the assistance of an experienced attorney.
How an Attorney Helps with MPN Disputes
When an insurance carrier denies your care or provides an inadequate MPN list, your best option is to find an experienced workers’ comp attorney. The right legal representative can assist with your dispute and overall claim in multiple ways, including by litigating before a judge, arguing for your specific medical needs, and handling the formal review process.
Litigating Before a Judge
When an insurance company does not behave as it should, an attorney’s primary recourse is to take the case before a workers’ compensation judge and compel them to explain their conduct. An unrepresented injured worker is unlikely to be able to complete this formal litigation process on their own. If they try, any error or missed deadline could cause their case to be dismissed entirely.
Arguing for Specific Medical Needs
Attorneys can directly confront specific disputes over care, particularly when an insurance company interferes with getting the right doctor. For example, if an insurance company removes a worker’s doctor from the MPN, an attorney can argue to a judge that forcing a change would disrupt the continuity of care. In other cases, a legal representative may fight to help a client find a doctor in the first place. If an attorney can prove an MPN list is inadequate, they may secure a judge’s authorization for treatment outside the network.
Handling Formal Medical Reviews and Paperwork
An attorney handles all the complex administrative processes required by the MPN system. This includes filing the correct paperwork, meeting all deadlines, and representing the worker in a formal proceeding like an MPN Independent Medical Review. Your attorney can also assist with managing separate legal-medical disputes, such as those that require a qualified medical examination (QME) panel.
Handle Any MPN Dispute with Experienced Workers’ Comp Specialists
The MPN system is designed to be confusing, and many injured workers are surprised to find they have very little control over their medical treatment. By finding an experienced workers’ compensation attorney, individuals can enforce their rights and secure the medical care they are entitled to.
The Law Office of Kneisler & Schondel has been fighting for injured workers in California for over 30 years. As certified specialists in workers’ compensation law, we understand the CA MPN rules and know exactly how to hold the insurance companies accountable. With our help, you can challenge unfair denials, secure your full benefits, and focus on what’s truly important: your recovery.
If your MPN is delaying treatment or denying your choice of doctor, you have the right to fight back. Schedule a free consultation with the experienced workers’ compensation attorneys at Kneisler & Schondel to get the support you need.
Medical Provider Network (MPN) Frequently Asked Questions
What is the Meaning of MPN in Insurance?
In insurance, MPN stands for medical provider network. For a California workers’ compensation claim, this refers to the specific, closed network of doctors, clinics, and specialists approved by your employer’s insurance company. This network is the only place an injured worker can get medical treatment for their claim to be covered.
What is an MPN Doctor?
An MPN doctor is a physician, specialist, or clinic that is on the approved list for a specific medical provider network. These doctors have an agreement with the insurance company to treat injured workers and often specialize in occupational medicine. In California, your primary treating physician for a workers’ comp claim must be an MPN-approved doctor.
What is an MPN Identification Number?
An MPN Identification Number is a unique code that the California Division of Workers’ Compensation (DWC) assigns to a medical provider network when it is approved. This ID number is used to officially identify and track the network. You can use this number to look up details about your specific MPN on the DWC website.
If your medical care is being delayed, denied, or pushed through an MPN you don’t trust, it’s time to get legal support.
Contact Kneisler & Schondel for a confidential consultation with a certified workers’ compensation specialist. We’ll evaluate your claim, protect your medical rights, and help you move forward with the care and benefits you deserve.