Defending Your MPN! A Sixty-Second Seminar in Workers’ Compensation Claims Handling

It’s no secret that injured workers and applicant attorneys dislike Medical Provider Networks (MPN). They exploit every loophole to escape an MPN to select a doctor of their choice to be the worker’s primary treating physician (PTP). For years, a popular method to escape an MPN was for the worker to request a physician in a specific medical specialty, such as an internist, cardiologist, podiatrist, etc. If the employer’s network did not have at least three available specialists in the desired field, the injured worker would be allowed to treat outside the network. That tactic worked reliably until September 2017 when the WCAB seemingly closed the door on it. Yet, employers didn’t immediately seize upon the change, and even though the Board struck another blow against the practice in 2019, many employers still allowed applicants to use such tactic unchecked. In this article we remind the employer community of the three case law decisions issued by the Board which hold that a worker can no longer automatically escape an MPN if the employer does not have at least three available specialists in the medical discipline designated by the worker:

First and foremost, let’s identify the three WCAB cases in question. They are:

1. Gorbanwand v. Pacific GIS, et al, 2019 Cal. Wrk. Comp. P.D. LEXIS 385
2. Elshami v. C&A Restaurants, 2019 Cal. Wrk. Comp. P.D. LEXIS 390
3. Stephanie Souza Puente v. Napa Valley Unified School District, 2017 Cal. Wrk. Comp. P.D. LEXIS 100

In the above three cases the Board ruled the medical specialty of the physician is not the determinative factor in deciding if an injured worker may leave the MPN. All the employer must prove is that its MPN has at least three available physicians capable of treating the industrial injury. Complying with the employee’s request for a certain medical specialist is not mandatory.

Some applicant attorneys still rely on the old rules to excise their clients from an MPN. They are expecting that the claims administrator is unaware of the three case law decisions mentioned above, and for the most part, they have been quite successful. Should this tactic be attempted against you, reference the three case law decisions, and send AA packing!