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California Medical Provider Networks: Another Aspect of SB 863 Needing Judicial Oversight

April 04, 2014 (1 min read)

Another aspect of SB863 needing judicial oversight is the failure of the MPNs to assist patients in obtaining appointments with in-network treating psychiatrists, while denying payment to non-network psychiatrists as "self-procured".  Instead of providing legally-required assistance, the Claims Adjusters (CAs) and MPNs are giving mentally-impaired patients, many of whom don't read or speak English, lists of mental health providers and leaving them to their own devices. 

These lists often comprise psychologists (who can't do medication management), and psychiatrists who don't treat WC patients.  Some of my patients have shown up at psychiatrists' offices after long drives, only to be told then that the doctor doesn't accept WC.  In addition, many of the MPN panels, especially in the Inland Empire, include few, if any, psychiatrists who treat injured workers through WC.  These flawed provider lists are only one step removed from the old "phantom networks".

A non-network psychiatrist, of course, can't abandon a mentally-ill patient on psychiatric medications just because an insurer wants to avoid payment by pretending that other treating doctors are available, when in fact they aren't.  Further, just receiving one of these denial letters constitutes a new and unnecessary stressor for patients who already require mental health treatment as a consequence of their occupational injuries.

As a practical judicial/administrative solution to this problem, I recommend a WCAB or DIR rule that before an insurer can deny payment for non-network psychiatric services, which otherwise comply with all WC standards as to medical necessity and fees, the insurer must provide the name and contact information for a qualified psychiatrist in the same geographic area as the patient who has actually accepted the case.  Documentation, including a definite appointment date/time (as for a PQME exam), and confirmation that the doctor's office accepts WC, should be attached to the denial letter, so the non-network doctor can effect a smooth transfer of care.

If the CAs and/or MPNs can't meet this performance standard, they should be estopped from objecting to non-network or "self-procured" psychiatric treatment, to which the realistic alternative for the injured worker usually is no treatment at all.