California’s Workers’ Compensation system is designed to provide timely medical treatment and financial compensation to workers injured on the job. However, over the years, the system has been reshaped by numerous reforms, many of which were aimed at controlling costs, streamlining processes, and ensuring that workers receive the highest quality medical care.
One of the most significant changes in recent decades was the introduction of Medical Provider Networks (MPNs) – a reform aimed at containing medical costs within the Workers’ Compensation system.
While MPNs were established with good intentions, their impact on the system has been extremely controversial among doctors, patients, and their workers’ compensation attorneys from Mission Viejo to Brea and all throughout Orange County.
The reason for this controversy is that MPNs have arguably contributed to severe and unintended damage to the quality of medical care injured workers receive – the exact opposite of what they were supposed to achieve.
What are Medical Provider Networks (MPNs)?
Medical Provider Networks were introduced as part of California’s Workers’ Compensation reforms in 2004, under SB 899. MPN networks consist of groups of selected healthcare providers – including physicians, physical therapists, surgeons, and other specialists – who are pre-approved with no clear guidelines other than track record and loyalty to the insurance company.
The idea behind MPNs is similar to that of a preferred provider organization (PPO) in general health insurance: by creating a designated group of providers, insurance companies can negotiate rates and control medical costs more effectively.
In theory, this would allow injured workers access to timely medical care while reducing the financial burden on employers and insurers. However, as with many well-intentioned reforms, the reality has proven more complex – and even corrupt, in certain circumstances.
The Issue with MPNs
One of the main criticisms surrounding MPNs is that workers’ compensation doctors within these MPNs may be reluctant to fully and ethically advocate for the best interests of their patients.
This partisan behavior and reluctance stems from the fear of being removed from the network by insurance companies, which wield considerable influence over which physicians are included in or excluded from an MPN.
As a result, many medical professionals find themselves compromised ethically and torn between delivering optimal care for injured workers and safeguarding their own livelihoods by favoring the desired outcomes of insurance companies.
The Power Dynamic: Insurance Companies and Doctors
At the heart of the problem lies the power dynamic between insurance companies and doctors. Insurance companies have significant control over the composition of MPNs, meaning they decide which physicians get to participate and remain in these networks.
For many doctors, being part of an MPN is essential for maintaining a steady flow of workers’ compensation patients. Removal from an MPN can result in a substantial loss of income, as doctors may lose access to a large pool of potential patients.
Doctors who advocate too strongly for their patients may find themselves facing pushback from insurers, particularly in cases where expensive treatments, extensive testing, or prolonged periods of disability are recommended.
The fear of being removed from an MPN, which could have severe financial repercussions for the physician’s practice, may lead doctors to under-treat or compromise on care in order to remain in good standing with insurance companies.
Therefore, this power dynamic not only gives insurance companies control over doctors but instills them with the ability to influence medical decisions in subtle and often harmful ways – to the ultimate detriment of the patients.
The Chilling Effect on Patient Advocacy
The primary concern is that MPNs create a chilling effect on patient advocacy, especially in complex or prolonged cases. Workers’ compensation patients often need specialized care, lengthy rehabilitation, or multiple surgeries, and the costs associated with such treatments can be high. If a doctor feels that recommending such treatments could jeopardize their status within an MPN, they may hesitate to fully advocate for what the patient truly needs.
For example, an orthopedic surgeon might be aware that a patient would benefit from a more advanced (and costly) surgical procedure. However, knowing that insurance companies may question the necessity of the treatment, the doctor might opt for a less effective but cheaper alternative. Similarly, a treating physician might limit the number of physical therapy sessions they prescribe, even if the patient would benefit from additional treatment.
In some cases, doctors have reported receiving direct or indirect pressure from insurance companies to modify their medical opinions. This pressure can come in the form of denied treatment requests, lengthy utilization review processes, or even the threat of exclusion from the MPN. Over time, this erodes the trust between doctors and their patients, as workers may feel that their medical provider is more concerned with appeasing the insurance company than with their well-being.
Which workers’ compensation attorney near me in Mission Viejo, CA can best help protect my rights?
At California Workers Compensation Lawyers, you can find knowledgeable and assertive specialists, ready to help you navigate MPN-related challenges with ease and without stress. Our team has extensive experience defending the rights of injured workers and can provide the legal support necessary to ensure your claims are handled fairly – including mitigating the impact of insurers’ pressure on medical decisions.
With us, you can rest assured that your best interests will be prioritized – so don’t hesitate. Reach out to us today to schedule an appointment at one of our six Orange County offices, and let us help you secure the care you need and deserve!
