Work Comp Medical Provider Network (MPN) Contracts

The new Comp laws that went into effect 1/1/05 allow employers and Comp insurers to create MPNs that employees injured after that date must use to receive medical care.

Employers and insurers don’t have to create these MPNs and if they don’t, then the injured worker can choose any treating physician after 30 days of directed care as most all did previously. It is anticipated that most employers and/or their comp insurers will create such MPNs or contract with an MPN created by others.

The expressed goal of these MPNs is to bring together experienced, knowledgeable physicians to deliver effective treatment with improved outcomes thus reducing overall costs. The immediate goal we will experience will be to get physicians to discount their fees.

Of note is the requirement of a MPN specialist to see any non-emergent patient referred by other members of the MPN within 20 days.

It is estimated that neurosurgeons not part of an MPN will experience a sharp reduction in access to these patients.

The MPNs are likely to contact neurosurgeons offering a contract to become a member of the MPN. These contracts must be very carefully read and considered as they may contain certain provisions potentially harmful to your practice.

The first provision to watch for is a % reduction in your surgical fees as determined by the Work Comp Official Medical Fee Schedule. Each neurosurgeon needs to decide if he/she wants to discount fees but realize that such a reduction does not guarantee you will see any patients, it only guarantees to reduce your compensation in caring for these often difficult patients and the extensive administrative requirements their care generates.

Another problematic provision is one in which the MPN can “sell” your agreement to other MPNs thus creating what is called a “Silent PPO” into which you will be cast almost always without your knowledge. If you allow such a “sale”, you will have to extend the discount you agreed to with the original MPN to any other MPNs into which you are put.

You should know that any other MPNs into which you might be put via the contract provision to sell your agreement have to honor the % reduction agreed to in the original contract you signed. These other MPNs cannot impose their potentially lesser pay scale upon you. Also, should you have a contract with these other MPNs to treat non-workcomp patients at some discount, that contract cannot be enforced upon you when it comes to treating work comp patients. For instance, it is my understanding that SCIF has contracted with the Blue Cross Prudent Buyer (BCPB) plan to be their MPN. If you already have a contract with BCPB for non-workcomp patients for some crummy % of Medicare, they can’t force you to honor that contract when caring for work comp patients.

It’s a jungle out there. Watch your back.

Randy Smith, M.D.
Editor, CANS Newsletter
1-27-05

More detailed information about MPNs and Silent PPOs is available from the CMA in their CMA ON-CALL documents #1907 (Silent PPO) and # 1932 (MPN). These documents are free to CMA members but are $2 a page to non-members. I recommend you get #1907 and cough up the $62 for this 31 page document if you have to. (www.cmanet.org then click on CMA ON-CALL then Workers Compensation)

The above comments are my own and generated from what I think I heard during the Workers’ Compensation session at the CANS meeting on 1/22/05 in San Jose .