Treatment outside MPN and expedited hearing (California)

[laesquire]

SCENARIO:

1. Defense transfers applicant into the MPN. Treatment is proceeding for several months.

2. Next for about 4 months applicant does not go to the MPN. No medical reports are received. The adjusters says no TTD report so cut off TTD.

3. Applicant Attorney picks as PTP a NON MPN doctor who says TTD. At an Expedited Hearing does Applicant get TTD?

[rosellavera]

California employers are not liable for the cost of medical treatment billed by providers outside the MPN when applicants have been properly given notice of the MPN.

The Workers’ Compensation Appeals Board issued a panel decision with regard to the liability of carriers and employers whereby the applicants self-procure medical treatment outside of the employers’ MPN, pursuant to Labor Code § 4605.

In Lane v. Big Lots Stores, et al., No. ADJ2708349 (October 13, 2008) The WCAB held that California employers are not liable for the cost of medical treatment billed by providers outside the MPN when applicants have been properly given notice of the existence of a network.

In particular, the WCAB stated, “Because defendant did not neglect or refuse to provide reasonable medical treatment through its MPN, applicant is liable for any medical treatment he chooses to self-procure pursuant to Section 4605 and he is not free to later assert that defendant is liable for the costs of any of that treatment. Nor may the treating physician seek payment from defendant for medical treatment that applicant chose to self-procure from the physician.”

This panel decision does not provide citable authority, but it does provide a strong argument for denying liens for self-procured treatment.

Courtesy of www.grancell-law.com

Research by ....Rose

[stevepsca]

1) Why was IW treating outside the MPN ?
2) Why did the IW not continue with the PTP/MPN ?
3) Why was a PTP not selected from the MPN list ? (the IW can be compelled to select/treat in the MPN)

If I were the ALJ... those would be the first questions... w/o those answers...No, there would be no TTD.

Rose and I are compatible typists...

[spreare]

Most often a carrier/ER does not comply with all of the necessary notification requirements. But as we read with previous posters on this thread, they act as if an MPN has legitimate control, when usual they do not: In short, MPN medical control is generally spurious, if applicant is knowledgable and motivated to challenge.

MPN NOTIFICATION & OTHER REQUIREMENTS

The following is a synopsis of the written notification rules and requirements which, if violated, prevent the employer/carrier from exerting medical control with an MPN.

LC 3350(e) Failure of an employer to provide the notice required by this
section shall automatically permit the employee to be treated
by his or her personal physician with respect to an injury
occurring during that failure.

CC&R 9767.12 Written notice of an MPN under 4616.3 must be made prior
to the injury and prior to the implementation of the MPN, at
the time of the employee’s hire, or when an existing employ-
ee transfers to an MPN.

An employer/insurer offering an MPN shall notify each
covered employee in writing about the use of the MPN 30
days prior to the MPN’s implementation, at the time of hiring
the employee or on transfer of an existing employee to an
MPN.

Written notification shall be sent to an employee at the time
of injury.

Written notification shall be in a language the employee can
understand, (English and Spanish)., and shall explain how to
contact the person in charge of MPN services, with a toll free
number if necessary. Notice shall contain a description of
the MPN and how to access the MPN’s provider directory
with a regional listing of the MPN providers. It the directory
is available on a website, it must be listed.

The notice must explain how to access care under the MPN
and how to access care if the employee is out of the MPN’s
service area.

It must explain how to choose an MPN doctor and what to do
if there are problems making an appointment, how to change
doctors within an MPN, and how to use the 2nd and 3rd
opinion process, and a description of the IMR (independent
medical review) process at the time of a 3rd opinion.

If the MPN changes, the employees shall be notified in 30
days in writing in a language they understand, (English and
Spanish).

[laesquire]

Good posts.

Applicant was getting treatmment within the MPN. Everything was fine.

Next applicant retained an attorney. The attorney knew of the MPN , but did not care. He sent applicant to a NON MPN Doctor. His theory is if the MPN notices do not stand up per the Knight case then Applicant gets the TTD per NON MPN doctor.

Thanks for the Big Lot Stores citation. I think that case is helpful to fight NON MPN treatment costs and arguably applicant staying within the MPN on the TTD argument.

[spreare]

Ok, but are you arguing that by virtue of the intial tx within the MPN, and "everything fine "( according to who?) IW waived all rights to tx outside MPN? I mean, are you saying that because IW initially tx within MPN, and "Everything fine." that remedied any initial notification defects?

[spreare]

And another point,seems to me the issue is whether ER is responsible to pay for TX and eval procured outside an MPN. if your client notifications were not defective, then they don't have to pay for tx; however (and someone can help me here) sometime in mid 2008 there was an en banc decision which stated that IW may procure tx outside his/her own expense, and that such reports are admissible, even if paid for by IW own coin. by this, your client may refuse to pay for self-procured tx, but such reports regarding TTD are admissible (assuming AOE/COE established) and physican is licensed in state to make TTD determinations..... And when you think abouty it, how does tx outside an MPN effect AOE/COE and disability status? if he is injured and disabled, it is what it is????

Can someone remember what that case was? seems to me it published in appx May of 2008, but not sure of exact date.

[chirogeek]

Can someone remember what that case was? seems to me it published in appx May of 2008, but not sure of exact date.

I've looked through all the en banc and significant panel decisions and could not find--although I remember there was an opinion on this matter. Anyone remember???

[davidd]

You might be thinking of Salgado vs. County of Orange, ADJ3664982 (LBO 0390702) 5/12/2008 - reported in WorkCompCentral News 7/24/08, and also Lane v. Big Lots Stores, et al., No. ADJ2708349, 10/6/08 reported in WorkCompCentral News 10/21/08. They are only panel opinions, NOT Significant Panels. Both said that the applicant can self-procure (and be responsible for payment) treatment outside the MPN and that the reporting of the self-procured physician is admissible.

[spreare]

davidd, that is exactly my point!I then why the coercive denial of ttd!!! bet I can't get anyone on the defense side to answer that here..