MPN Evolution from Provider Perspective (California) (Califo

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MPN Evolution from Provider Perspective (California) (Califo

Postby theAxe on Tue Jan 31, 2012 10:37 am

Initially when MPNs were beginning, the medical provider was told that in order to be part of an MPN they MUST agree to accept a "PPO" reduction several percentage points below official medical fee schedule from the IC in exchange for the ability to treat patients - most referrals were made by the industrial clinic to their prefered specialists - but docs who wanted to treat WC patients needed to be in the MPNs so they agreed.

Large MPNs were established - many with physicians who had no comp knowledge or interest - having been co-opted by Blue Cross or a simular entity. These then evolved into large MPN orginizations listing many many physicans interested in treating WC patients and with whom many many ICs contracted for MPN provisions such as Coventry or Corvel - however some of those docs were not solely defense focused.

As the WCAB continued to interpret and restrain treatment and IC became more attuned to the MPN requirements, the AAs seem to have capitulated for the most part and started referring IW for treatment to physicians listed online in the IC website, which mostly referred to the listings like Coventry or Corvel.

The medical providers began to notice that "PPO reductions" were being taken by IC concurently on some cases when the same IC was arguing that the doc was not part of their MPN on others -- This was explained by stating that some of the employers with the IC had chosen to be part of a special "carve out" MPN, so that patient was prohibited from treating, but with employers with no MPN or if treating within the greater non-carve out MPN the IC was entitled to take their PPO reductions. The doc was told that it was still beneficial for them to accept less in payment on the chance that they could treat within the larger MPN.

Now we are seeing carriers who state they have only one MPN which has nothing to do with the larger listings like Coventry or Corvel - while still participating with those entities solely so that they can take the PPO reductions on non-MPN cases.

Attorneys and IW frequently go to the website listings - assuming that the physicians listed are w/in the MPN - when in reality, the docs are only entitled to accept less money if the IC loses the MPN arguement. The physicians who are cut out of the ability to treat, usually get no notice that the "actual" MPN has changed and that their only connection with the IC now is an agreement to take less money if they get paid at all.

With the latest ruling that no reports from non-MPN providers will be admissible, combined with the fact that none of the MPNs are willing to accept new physician applicants - combined with the fact that most docs within the "carve out" MPNs know they are only there at the sufference of the IC and are only authorized to see the "accepted" areas of injury regardless of the law regarding evaluation of all areas "claimed"- I forsee many good treating docs leaving the system - leaving the IC in full control and the IW out in the cold - especially when the treatment provided or lack of treatment causes compensible consequences.

So much for a benefit system to cure or relieve the IW from the effects of their industrial injuries...
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Re: MPN Evolution from Provider Perspective (California) (Califo

Postby doc154 on Sat Sep 28, 2013 4:49 pm

I just saw a young man/truck driver who overturned his truck on a freeway. His adjustor sent him a list of 8 local MPN orthopedic surgeons, but his father called all 8 of the offices and none on them accepted worker's compensation patients. I suppose they can find more profitable ways to spend their time. I was surprised that no one would see a worker's compensation case out of eight doctors and was wondering how unusual this is. He does have an attorney who advised him to just go to an ER.
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Re: MPN Evolution from Provider Perspective (California) (Califo

Postby jonbrissman on Sun Sep 29, 2013 8:55 pm

Prior to signing, contracts are negotiable. I recommend to my physician clients that they negotiate to allow PPO reductions only on accounts where the injured worker was referred by the PPO signatory or participant. I also recommend that a provision be inserted that the PPO discount does not apply to accounts that remain unpaid after thirty days.

Consider: If a physician is bound to allow a 10% PPO discount on twenty patients in exchange for receiving one patient referral for treatment through the PPO, isn't the physician losing revenue by joining the PPO? Wouldn't he be better off by not joining the PPO and billing 100% on those twenty patients and not obtaining the single referral? However, joining a PPO makes economic sense if the discount is limited to the account of the referred patient.

Medical offices should evaluate the number of referrals they obtain through the PPO and calculate the discounts given on non-referred patient accounts to determine cost effectiveness.

The same rationale applies to MPNs.

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