California: Another Nuance to Treatment Outside of the Medical Provider Network

California: Another Nuance to Treatment Outside of the Medical Provider Network

There have been many cases as of late dealing with Medical Provider Network (MPN) issues. Valdez v. Warehouse Demo Services (2011) 76 Cal. Comp. Cases 970 held that treatment reports obtained by physicians outside of the defendant’s MPN were not admissible and defendant was not liable for the cost. As with any legal issues, there are often exceptions to the general rule. For example, what happens if the injured worker files a claim of injury to multiple body parts and the defendant accepts some but not all of the body parts?

That was precisely the issue presented in Paris v. Savolt Industries, Inc., 2012 Cal. Wrk. Comp. P.D. LEXIS – [free access]. There, applicant had filed an a claim of injury alleging that while employed by defendant on November 28, 2003, he sustained industrial injury to his spine, left upper extremity, and leg. Defendant admitted liability to the spine and leg, but denied the left upper extremity. In December 2003, applicant began treatment with Clayton E. Patchett, M.D. for his industrial injury, including his left upper extremity.

Subsequently, applicant filed another claim of injury alleging cumulative injury to November 28, 2003, to both his upper extremities and his spine. Defendant denied the cumulative trauma claim and in May of 2007, applicant began treating with Phillip A. Sobol, M.D. Applicant continued to treat with Dr. Sobol as his primary treating physician for all body parts, not just the upper extremities. Defendant notified Dr. Sobol that he was not within the MPN and that applicant had been treating within its MPN since 2005.

The Workers’ Compensation Judge (WCJ) found that defendant was not liable for the costs associated with Dr. Sobol’s treatment as it was procured outside of defendant’s MPN. On reconsideration, applicant argued that defendant lost control over medical treatment when it initially denied applicant’s upper extremity injuries and that based on that initial denial, applicant should not now be compelled to treat within the MPN.

On reconsideration, after first reciting the facts, the Commissioners reviewed Labor Code Section 4600 as well as the rules applicable to MPN’s. The Commissioners found:

With respect to the MPN dispute, i.e. the validity of the MPN and the transfer of applicant’s care, we find that there was a validly established, properly noticed MPN. (Defendant’s Ex. J) and applicant is required to continue treatment within the MPN for the accepted body parts. (Valdez v. Warehouse Demo Services (2011) 76 Cal. Comp. Cases 970.) Regarding applicant’s self-procured medical treatment, Dr. Sobol is entitled to be paid for medical treatment only for the upper extremities because defendant denied these body parts. Defendant’s failure to provide reasonably necessary medical treatment as required pursuant to section 4600, justified applicant self-procuring medical treatment at defendant’s expense from Dr. Sobol for his upper extremities. (McCoy v. Industrial Accident Comm. supra. 64 Cal.2d 82 [31 Cal.Comp.Cases 93]; Knight v. United Parcel Service. supra, 71 Cal.Comp.Cases 1423.)

Accordingly, when considering whether treatment was obtained outside of the MPN, it will be critical to first determine if all of the alleged body parts were accepted by defendant. If not, and if the non-MPN physician was providing treatment for those denied body parts in conjunction with the accepted body parts, in the event of a finding of industrial injury to the denied body parts, the treatment outside of the MPN may, at least to a partial extent, be the defendant’s liability. Additionally, though not explicitly stated, it can also be implied that the reports of the non-MPN physician would also be admissible, at least to the extent that it is being used to prove a disputed issue relevant to the denied body parts.

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