“An employer or insurer that offers a Medical Provider Network Plan under this article shall notify each covered employee in writing about the use of the Medical Provider Network 30 days prior to the implementation of an approved MPN, at the time of hire, or when an existing employee transfers into the MPN, whichever is appropriate to ensure that the employee has received the initial notification. The notification shall also be sent to a covered employee at the time of injury. The notification(s) shall be written in English and Spanish. The initial written notification shall include the following information: (1) How to contact the person designated by the employer or insurer to be the MPN contact for covered employees. The employer or insurer shall provide a toll free telephone number if the MPN geographical service area includes more than one area code…”

 

After my initial interview with the patient, he stated that he was never given any notification of the existence of an MPN.  Therefore, we believe that the employer/insurer has lost the right to control medical care within an MPN because of these violations.  This opinion was supported in a recent WCAB panel decision of Metoyer v. Wilshire West Dental; Zenith Ins. Co. (2005) LBO 368875.  In Metoyer a panel of three commissioners upheld a WCJ’s opinion that an injured worker could treat outside an insurer’s MPN because the employer failed to comply with the work-place notification requirements of Labor Code section 3550; furthermore, they opined that if the employer would have violated Title 8 CCR section 9767.12, the injured worker may also be allowed to treat outside an insurer’s MPN. More explicitly, commissioner Rabine wrote:

"Additionally we [the WCAB commissioners] note that AD rule 9767.12 provides for required notices to be given prior to an injury, specifically written notice of a medical provider network under Labor Code section 4616.3 prior to the implementation of an approved MPN, at the time of higher, or when an existing employee transfers into the MPN. While specific consequences for a failure to provide required notice are not described in AD Rule 9767.12, when coupled with the aforementioned Labor Code section [section 3550(e)], the consequences herein may be justified."

If our assertion is untrue, please send us a copy of the MPN "initial notification" that was issued to the employee before said industrial injury occurred.