MPN issues (California) (California)

[rider001]

IW has accepted carpal tunnel case and denied body part. AME refusses to confirm additional body part but has reffered the IW to two specialist. Both specialists the AME referred to confirm the additional body part. Still AME refuses to accept the additional body part but at least deffered to the speicalist opinion.

IW has been treating with non-mpn physician for both accepted body part and denied body parts.

Lien is for medications. I understand that since the IW is treating with non-mpn physician that the treatment for the accepted body might not be reimbursable.

Would I prevail if PTP wrote a report separating what medications would be prescribed for the accepted body part and what medications were prescribe for the denied body?

My guess is the bulk of the medications are prescribe for the denied body.

IC has not been sending medication requests to UR.

I would like to continue filling medications for the IW but the case is so complicated. Any suggestion on how to posture this one will be appreciated.

[earthwake@aol.com]

I have dealt with that same issue before, DO NOT TRY TO SPLIT THE MEDICATIONS LIKE THAT. The reason being is that the insurance company has already denied the bills, making any changes or adding anything that favors the applicant is going to cause you a world of trouble. The insurance calls this fraud. The only time they want you to split stuff up is when you are dealing with comments in regards to personal injury and work injury. The best course of action I can see would be writing the AME and requesting that he comment on your bills. If that doesn't happen then it is left to the PTP to make his opinion on the medication, sense the insurance opted Not to have them comment on the medication it is up to the opinion of your prescribing Dr. to comment. And that usually favors your position. I hope any of this helps. If you need specific LC let me know and I can send it.

[steve appell]

Writing the AME to comment on your billing is Ex Parte communication, and you could get sanctioned. Therefore, I would not do it. Additionally, it appears your CIC is not yet resolved. Therefore, you as a lien claimant arguably have no standing to participate in the AME exam. Lastly, if the IC has not been sending the medication requests to UR, the meds are allowable per Sandhagen on the admitted body parts. Therefore, I would wait for the CIC to settle and then file a DOR for a lien conference.

Good Luck!

[gaiassoul1@yahoo.com]

Would I prevail if PTP wrote a report separating what medications would be prescribed for the accepted body part and what medications were prescribe for the denied body?

If they can be specifically related but if you have for say for instance overlapping orthopedic claims with pain and then the standard GERD medication due to gastrointestinal irritation, I would think they would be too intertwined, however, if you have a burn for instance that has a silver nitrate cream prescribed, then that could be easily separate.

I would like to continue filling medications for the IW but the case is so complicated. Any suggestion on how to posture this one will be appreciated.

There are two schools of thought on MPNs:

First, the applicant is limited to one treating physician and since the dispute regarding other body parts is not yet resolved and MPN physicians are not usually authorized to treat disputed body parts, the applicant has no choice but to continue with a non-MPN physician. (advocated by lien claimants and applicant attorneys)

Second, the MPN treating physician is mandated per CCR 9785 to provide a full examination of all alleged industrial complaints and must in his/her initial evaluation opine why the disputed body parts are not industrially related or carry out reasonable diagnostics to rule-out industrial causation. (advocated by defense attorneys)

So what interests me is I rarely see a carrier direct a MPN treating physician to follow the second path, so why can't an applicant attorney slap his client into an MPN and then request requirecd aforementioned reporting and upon the failure of the treating MPN physician to address the disputed body parts, petition the AD for a change of primary treating physician?

I know the answer, so my question is rhetorical, that applicant attorneys work on a volume practice and the above process is arduous and time consuming with no financial reward.

So have you even assured that the defense have what is required to assert an MPN? I.e., employer notice of the MPN at the time of hire or within 30 days of the inception of the MPN as well as the notice to the applicant to opt out of the MPN by pre-desgnating a personal physician? You as a lien holder have a right to this discovery and in my experience, not many emmployers get this right and can rarely sustain the MPN defense.

[rider001]

Just about every MPN requirement has not been met. However case went to trial and MPN issues were glossed over by the applicant because more pressing issue were being raised. IW subsequently order into MPN. Writ filed but not on MPN issues.

Does the MPN order then become binding on the lien claimants or do we get a second bite of the apple at lien trial?

MPN issues to be raised by lien claimant which were not rasied by applicant:
There are no pain management doc's on MPN listing for entire county. IW has been treating with Pain Mangement for years. IC has said to use a Physical Medicine & Rehab (PM&R) doc. IW has objected does not want PM&R. No PM&R docs within 30 minutes or 15 miles 9767.5 (b) roads frequently closed do to ice etc. No work posting. No chance to predesignated. Transfer of Care form completed in 2007 no authorization or response from IC. Planned spinal cord simulator authorized by AME in 2007 but contiunally denied by IC because of MPN issues.Trial stim finally done under Medicare.

The medication prior to the MPN order i am confident i can get paid at trial, it the medications after the MPN order i am now questioning.

Thoughts

[bcurnick]

CCR 9785 says there is only one PTP at a time. If the doctor is reporting on all alleged body parts as required, he would be the only physician performing the duties of the PTP and therefore all medications prescribed by this physician should be paid. DO NOT SPLIT THE MEDICINES BASED UPON AN MPN......