Doctor Calls MPN Bluff, Gets 100% OMFS

Doctor Calls MPN Bluff, Gets 100% OMFS

Recently, a daisyCollect client demonstrated how California providers can shake up — and potentially shake off — the bloated, crippling, and largely illusory Medical Provider Network (MPN) system.

This doctor secured reimbursement from the State Compensation Insurance Fund (SCIF) at 100% of the Official Medical Fee Schedule (OMFS) rates. No contractual discounts, no leftover reimbursement scraps from a network entity’s table, no sub-Medicare rates for treating injured workers.

How? By simply operating as though MPNs are nothing but a mirage.

The story below should inspire California providers to do what has always been within their power: to say no to rapacious discount reimbursement agreements in exchange for MPN membership.

Providers, you don’t need the MPNs; the MPNs need you.

Without providers, MPNs cannot comply with the mandated access physician standards. If most providers did exactly what this specialist did, claims administrators would be forced to reimburse all providers at OMFS rates.

By collectively refusing to participate in MPNs requiring reimbursement discounts, providers can STOP sub-OMFS reimbursement.

Specialist Bills (and Receives) 100% OMFS

An injured worker required a consultation that the Primary Treating Physician (PTP) wasn't qualified to perform, necessitating a referral. MPN regulations stipulate that any specialists needed for appropriate care must be available within a certain distance of the injured worker’s home or place of employment.

No appropriate specialist (who would accept sub-OMFS reimbursements) was available within the designated radius.  As such, SCIF had no choice but to allow the injured worker to seek consultation with a provider outside the applicable MPN.

As shown in the email below, a specialist who was not in the SCIF MPN provided the necessary consultation. This specialist billed 100% OMFS rates for the services rendered — and SCIF paid 100% OMFS rates.

No Preferred Provider Organization (PPO) discounts, no network reductions, no payment nonsense. The specialist received correct reimbursement at the rates California deemed appropriate, given the practice expenses of treating injured workers.

Provider Power Is Real

What does this mean for other California providers, not to mention injured workers? Potentially, everything.

The real power lies with providers. Without provider participation, MPNs cannot meet legal access standards.

If a significant number of providers (especially specialists) reject MPN membership, claims administrators would be cornered into paying full OMFS rates. Providers can challenge the status quo by declining or canceling any agreement that imposes reimbursement discounts as the price of participating in an MPN.  

The notion that MPN membership is necessary to treat injured workers is a misperception on the part of providers, one that’s been exploited for too long. It's time to take action and flip the script.

The MPN Mirage

Currently, physicians across California are paid financially unsustainable reimbursement rates for treating injured workers, largely due to the opaque MPN system.

Legally, employers or their workers’ comp insurers may restrict care for work-related injuries to an MPN, theoretically a circle of trusted providers from which an injured worker may choose. But in practice, California has failed to implement a system that allows providers to determine which employers and insurers maintain approved MPNs.

Claims administrators often deny payment, citing the provider is “out of network” (whether true or not) or send authorizations demanding treatment to be provided in-network. Consequently, providers agree to contractual discounts to ensure MPN membership, often accepting Medicare rates or less — despite OMFS rates set at roughly 140% of Medicare rates to account for the extraordinary administrative costs of treating injured workers.

However, this all rests entirely on a just-trust-us system of nudges and winks — because there is absolutely no reliable way for a provider (or applicant attorney) to verify whether an MPN cited by a claims administrator applies to the injured worker. Providers just believe they must participate in MPNs to treat injured workers (spoiler alert: they don’t).

Providers, it’s up to you—demand 100% of the OMFS by refusing to capitulate to threats of MPN exclusion. Remember: MPNs need you.

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