Medical Provider Network
Medical Provider Network medical billing services

Medical Provider Network (MPN)

In California, the medical provider network (MPN) is established by the workers compensation insurance carrier or self-insured employer and approved by the Division of Workers’ Compensation's (DWC) Administrative Director to treat injured workers on the job.

Points to keep in mind while choosing a medical billing company :

In California, injured workers are entitled to medical treatment as part of their workers' compensation claim. However, not just any doctor will do. If an insurer or employer establishes a Medical Provider Network (MPN), the injured worker must be treated by a doctor within that network.

Each employer can customize their own MPN to fit their needs, but the network must give injured workers access to medical treatment. The network must have enough doctors to treat common work injuries in all geographic areas where an injured worker may live. This ensures that everyone has access to quality medical care, regardless of their location.

MPN’s are beneficial for employers, employees, and insurance carriers. Employers maintain control of the medical care; injured employees obtain the medical care needed and insurance carriers mitigate costs. A tremendous amount of effort is put in place to create an MPN and select physicians familiar with industrial injuries and handling of authorizations for treatment.

Accessibility of the Medical Provider Network :

An MPN must have providers and specialists who can treat common injuries experienced by the injured employees within 60 minutes or 30 miles of a covered employee's residence or workplace. This will ensure that employees receive timely treatment for their injuries.

Benefits or advantages of Medical Provider Network:

  • Medical Control
  • Medical Cost Savings
  • Quality Physicians
  • Appropriate Medical Treatment

All seems perfect, till here! BUT
Did the implementation of MPN’s achieve why they were implemented at its first place.

No, MPN's were established as a method of controlling costs. Unfortunately, they often fail to benefit anyone. In many cases, they are used to hold back injured workers from obtaining the necessary treatment and prevent providers from receiving reimbursement for services.

Insurers and employers often deny payment to providers who are not included in their MPN. However, this is often not the case, as many providers are included in the MPN or the insurer or employer does not even have an active MPN.

Medical providers when they receive the denial based on non-MPN medical treatment.

There are only 344 approved MPN’s out of 2,477 MPN’s in total. The first and most critical step in determining whether an applicable MPN applies is to determine how the employer for the injured worker maintains workers’ comp coverage. When we receive a denial based on non-MPN provider, we check the following to determine if the bill was dubiously or falsely denied and submit for reconsideration based on facts.

  1. Determine the Employer’s Workers’ Comp Coverage
  2. Determine Whether Employer/Insurer Maintains Approved MPN
  3. Determine provider participation in the MPN or network.

Invalid denials of care based on NON-MPN are often fought in court and won, as this is simply a delaying or denying reimbursement tactic used by insurers. In some cases, even claims adjusters are unaware of what MPN the employer is under or which MPN applies to that employer or if that is even an Active MPN.

In a Nutshell:

The medical provider network (MPN) system is a significant problem for healthcare providers who are treating injured workers. The complexities of the MPN system often punish injured workers by depriving them of the required care in a timely and efficient manner. The MPN system needs refinement or to be fully removed in order to ensure that injured workers can receive the care they need.

At Meraki RCM Solutions, LLC, we work hard to ensure the best outcome for our clients (medical providers) who are treating injured workers. We take care of all the paperwork and negotiations so that the medical providers can focus on what are important - healing their patients. We are here for medical providers at any stage they feel in need of help. Whether you're just starting out or you've been in the business for a while, we can provide you with the resources and support you need to succeed.

Reach out to us at 375-0472.

Tag: Medical / Provider / Network

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