Compensation
MEDICAL PROVIDER NETWORK
FREQUENTLY ASKED QUESTIONS
Q What is a Medical Provider Network?
A- It is a network of physicians, some of which primarily treat occupational injuries
and others who primarily treat non-occupational conditions designed to provide
injured employees prompt access to quality medical treatment.
Q As an employer am I required to establish a medical provider network?
A- No. Establishing a medical provider network is optional but establishing one does
provide some advantages to the employer such as increased medical control.
Q What is the process for establishing a medical provider network?
A- We have simplified the application process for our customers. Simply contact
your Account Executive or Christine Gerbasi at cgerbasi@keenanassoc.com.
Q Are Medical Provider Networks new? Didn’t employers always have the right to
control medical treatment?
A- Medical Provider Networks were introduced by SB 899, which was approved and
went into effect April 19, 2004. SB 899 allows an employer to establish a medical
provider network anytime on, or after 1/1/05. Prior to SB 899, and continuing if an
employer chooses not to establish a medical provider network, an employer has
medical control the first 30 days. After the first 30 days an employee can change to a
physician of their choice. Whether or not an employer establishes a medical provider
network or not, if an employee appropriately predesignates their personal treating
physician, in writing, prior to their industrial injury, the employee can treat with their
predesignated physician.
Q Once a medical network is established, who has medical control?
A- Unless the employee has appropriately predesignated their personal treating
physician (in writing and prior to the date of injury), the employer shall select the
initial treating physician from within the medical provider network and begin
treatment. The employee does have the right to change physicians after the initial
visit to a provider within the network. Note that to maintain treatment within the
network it will be critical that request for a change of physician is responded to
within five days of receiving the request (as currently required by Labor Code
Section 4600).
This information has been provided to communicate recent legislative developments that may be of interest to
our clients. Please understand we cannot give legal advice and we encourage you to contact your Legal Counsel
for legal advice on these issues.
Q What are the benefits to an employer if they establish a medical provider network?
A- The primary benefit is increased medical control. For the most part, a medical
provider network will allow an employer medical control for the life of the claim.
Q Will medical provider networks apply only to dates of injury on or after 1/1/05 or
does it apply regardless of date of injury?
A- The law clearly allows employers, with some exceptions, to transfer medical care
into an approved medical provider network. Some applicant attorneys feel this is
unconstitutional and are preparing to challenge this issue in the courts.
Q What impact does an MPN have on an employee’s rights should they be injured
on the job?
A- Employees still have the right to predesignate their personal treating physician
(must be their regular physician or surgeon; must be their primary care physician
who has previously directed the medical treatment and who retains the medical
records/history; and the physician must agree to be predesignated). If the employee
does not predesignate prior to the injury, the employer refers the employee to an
MPN provider. After the initial visit, the employee can elect to change physicians to
another MPN provider. Participation in an MPN does not alter an employees right
to medical treatment or benefits. The goal of an MPN is to streamline and expedite
quality medical treatment and facilitate getting the employee back into the working
environment as early as medically appropriate.
Q What happens if I elect not to establish an MPN?
A- It is essentially business as usual. As the employer, unless your employee has
properly predesignated their personal treating physician, you will have medical
control for the first 30 days. After the initial 30 days your employee can select any
physician to treat with. Understand that if you do not establish an MPN, you lose the
ability to transfer medical care of existing claims to an MPN provider of your choice.
Q Assuming medical provider networks apply to all dates of injury, does this mean as
of 1/1/05 medical treatment can be transferred from a non-network treating
physician to a physician within the network?
A- Yes, again with some exceptions. Of course each case should be evaluated
individually to ensure the well being of the injured employees is considered. Some
cases where surgery is scheduled or medical treatment is at a critical point should not
be immediately transferred. Appropriate and timely medical treatment and the
injured employees full recovery is the number one priority.
Q If an injury is questionable should the employee be referred to a provider within
the medical provider network?
A- Absolutely! Labor Code Section 5402(c) now requires that medical treatment be
provided within 24 hours, including delayed claims, up to time of the denial or
$10,000.
This information has been provided to communicate recent legislative developments that may be of interest to
our clients. Please understand we cannot give legal advice and we encourage you to contact your Legal Counsel
for legal advice on these issues.
Q How many and what type of physicians must be included in the network?
A- The exact number of physicians is still unknown. The law tells us that the
network must consist of an “adequate number” of physicians to ensure injured
employees have access to medical treatment. The law does indicates the type of
physicians as outlined in Labor Code Section 3209.3 and Labor Code Section 3209.5
(physicians or surgeons holding an M.D. or D.O. degree, psychologists
acupuncturists, optometrists, dentists, podiatrists, and chiropractic practitioners, etc.)
Q As an employer, doesn’t SB 899 say I have the “exclusive right to determine the
members of my network”?
A- Yes. However the rules and regulations governing medical provider networks
provide some specific parameters that must be followed to ensure injured employees
have appropriate access to medical care.
Q What is Keenan & Associates doing to prepare customers and develop a medical
provider network?
A- Keenan & Associates has introduced a Medical Provider Network solution called
the PRIME Advantage Medical Network which is a partnership with Blue Cross.
Blue Cross is a certified Health Care Organization (HCO) and already deemed to
meet the qualifications of a Medical Provider Network. We have also developed
tools to assist employers in communicating all aspects of the medical provider
networks to their employees.
This information has been provided to communicate recent legislative developments that may be of interest to
our clients. Please understand we cannot give legal advice and we encourage you to contact your Legal Counsel
for legal advice on these issues.
Q What information will Keenan be providing to employers who want to establish a
medical provider network?
A- Keenan, in partnership with Blue Cross, has prepared the entire application
template for submission to the Department of Workers’ Compensation for approval.
In addition, Keenan has developed educational material to assist their customers
communicate information to their employees, their union representatives and
member districts who are part of the larger JPA. Information available includes:
 Information to explain what a medical provider is
 Employee notification material explaining the program and the employees
rights in detail
 Information on how to access the medical provider network directory of
physicians and providers
 The process for injured employees to select a physician within the medical
provider network after the initial visit
 Process for the injured employee to obtain a second and/or third opinion as
well as how to obtain an Independent Medical Review
 Process for how medical continuity of care will be handled should a
physician or provider be terminated from the network
 Process for transferring medical care into the medical provider network if the
current treatment is outside the network
 Contact information should the employer or the injured worker require
assistance accessing the network directory or obtaining an appointment
Q What should employers be doing to prepare?
A1. The most effective thing employers can do now is to refer injured employees to
front line medical providers that are within the Blue Cross network. You can
verify that your front line provider is part of the network by visiting the Workers’
Compensation Provider Finder link on our web site at www.keenanassoc.com. or
by contacting Keenan & Associates.
2. If you have had a long standing, positive relationship with a front line medical
provider that is not part of the Blue Cross network please contact your local
Keenan & Associates Claims Manager so the provider can be nominated into the
network.
3. Notification to your employees is critical. Some applicant attorneys are indicating
they will try to opt out of the network by arguing the employer failed to notify
the employee of their right to predesignate their personal physician. It is a good
idea to have your employees sign an acknowledgement that they received
information regarding their right to predesignate their personal physician.
Additional questions or comments can be directed to either Christine Gerbasi at 310-212-0363 x 3760
cgerbasi@keenanassoc.com or Susie Crane at 310-212-0363 x 3900 scrane@keenanassoc.com.
This information has been provided to communicate recent legislative developments that may be of interest to
our clients. Please understand we cannot give legal advice and we encourage you to contact your Legal Counsel
for legal advice on these issues.