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April 28, 2011

Case Note: Elayne Valdez v. Warehouse Demo Services

Summary:

How important are Medical Provider Networks (MPN) for employers in fighting unauthorized treatment? More important than ever. In a recent WCAB en banc decision issued on April 20, 2011, the WCAB made it clear that when there is a valid medical provider network (MPN), and the injured worker obtains treatment outside the MPN, the employer and carrier will not be liable for the costs of that treatment, and more importantly, those reports will be inadmissible.

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How important are Medical Provider Networks (MPN) for employers in fighting unauthorized treatment? More important than ever. In a recent WCAB en banc decision issued on April 20, 2011, the WCAB made it clear that when there is a valid medical provider network (MPN), and the injured worker obtains treatment outside the MPN, the employer and carrier will not be liable for the costs of that treatment, and more importantly, those reports will be inadmissible.

In Elayne Valdez v. Warehouse Demo Services (ADJ7048296), the injured worker sustained an admitted injury and was initially sent for medical treatment with a physician within the Defendant’s MPN. Approximately three weeks later, the applicant retained legal counsel and she began treating with a physician outside the MPN. An issue arose over the applicant’s entitlement to temporary disability based upon that treatment, and the matter proceeded to Trial. At Trial, the Workers’ Compensation Administrative Law Judge (WCJ) found, based upon the reports of the non-MPN physician, that the applicant was entitled to temporary disability (TD) benefits for a specified period of time, less any payments received from the Employment Development Department (EDD) during that time period, whose lien was allowed. The Defendant filed a timely petition for reconsideration of the WCJ’s decision. The applicant did not file an answer to the Defendant’s petition.

At the Workers’ Compensation Appeals Board (WCAB), a majority concluded that when there is a validly established MPN for which the proper notices have been provided employees and injured workers, the reports of non-MPN physicians are inadmissible and cannot be relied upon. Further, the WCAB went on to say that defendants are also not liable for the cost of the non-MPN reports.

In reaching the holding set forth above, the WCAB concluded that a validly established and properly noticed MPN existed. Therefore, it is important that employers and insurance carriers ensure that (1) their MPN is validly established, (2) that all MPN requirements have been met, (3) that the required notices are provided to all employees and injured workers, and (4) that documentation is retained that can establish that the required notices were and have indeed been provided. If accomplished, defendants can ensure that injured workers will be required to receive treatment within the MPN where medical costs can be contained. Also, if injured workers elect to seek treatment outside the MPN, defendants will not be liable for the cost of the reports provided by these non-MPN physicians.

Although such law has been in existence since 2004, only now are we seeing the benefit of the legislature’s intent. This case clearly exemplifies the original basis for the statutory creation of MPN’s — MPN’s save employers money.

Authors
Rick Goldman collaborated with Kristi L. Ellison and Rudy H. Lopez in writing this article. Ms. Ellison currently represents employers, self-insureds and insurance carriers in all aspects of Workers’ Compensation defense. Mr. Lopez currently represents employers, self-insureds and insurance carriers in all aspects of Workers’ Compensation defense, including 132a and Serious and Willful claims as well as coverage matters.

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About the Author

As a Certified Specialist in Workers’ Compensation Law, Rick Goldman has practiced exclusively in all aspects of defense of Workers’ Compensation claims with a vast experience in subrogation, retirement hearings and civil litigation involving the management side of employment and labor matters.

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