Third-Party Administrator (TPA) Sedgwick Claims Management Services, acting on behalf of ACE American Insurance Company, refused to consider authorizing care recommended by a Qualified Medical Evaluator (QME), and requested by the defense attorney, for an employee of Trader Joe’s.

Why does Sedgwick refuse to conduct Utilization Review (UR) and authorize the treatment? According to the letter from the Sedgwick adjuster, the reason for the denied authorization was that the requesting doctor was not in the appropriate Medical Provider Network (MPN) — an ACE American MPN that daisyBill later discovered was terminated.

A reasonable question: once Sedgwick refuses to process a Request for Authorization (RFA), how does California, Sedgwick, ACE, and Traders Joe’s expect the injured worker (or their attorney) to find a doctor eligible to provide the QME-ordered care?

Seemingly, no one cares.

This tale of California MPN chaos clearly demonstrates that even defense attorneys cannot navigate how to access care for injured workers. Effectively, MPNs do not restrict care to a trusted circle of providers, as MPNs were supposedly designed to.

Instead, MPNs slam the brakes on care (and reimbursement for care) at every turn.

Defense Attorney Instructs Doctor to Treat Injured Worker

Below is a letter from the defense attorney to the doctor, explaining the following:

1. A QME recommended a thumb steroid injection for a Trader Joe’s injured employee, and
2. The doctor should submit a Request for Authorization (RFA) “for any treatment you feel appropriate for the thumb,” and
3. Thanking the doctor, in advance, for “your report in this regard.”

Many doctors hesitate to provide care recommended by Medical-Legal evaluators because claims administrators often deny payment due to a lack of employer authorization for the recommended care. But in this case, the care is recommended by a QME and requested by the defense attorney.

Presumably, Sedgwick should approve and pay for the care this worker requires.

The doctor complied with the defense attorney’s request (and the QME’s recommendation) and submitted an RFA for the recommended thumb care.

Sedgwick Refuses to Process RFA

Rather than authorizing the QME-recommended treatment, Sedgwick sent the injured worker a letter stating that Sedgwick would not process the RFA because the request came from a non-MPN doctor.

While ACE American, as the insurer for Trader Joe’s, maintains 77 California MPNs, the letter failed to list which of the 77 MPNs maintained by ACE applies to the Trader Joe’s employee.

Finally, the letter instructs the injured worker to obtain care by contacting the injured worker’s attorney.

Trader Joe’s MPN: Terminated

As we explain in this post, to determine which MPN (supposedly) applied, daisyBill reached out to Sedgwick. After multiple phone calls over the course of over an hour, our agent managed to reach the Sedgwick adjuster, who claimed the applicable ACE American MPN was the “Sedgwick/Harbor 2 MPN.” When pressed for the MPN ID number, the adjuster could only offer a phone number and website for Sedgwick California MPNs, which provided no helpful information.

Of course, by checking the Division of Workers’ Compensation (DWC) online MPN list, our agent discovered that the ACE American Insurance Sedgwick/Harbor 2 MPN was terminated. 

Sedgwick refused to authorize care because the terminated ACE MPN did not list the doctor requesting the treatment. Further, we wonder how the adjuster searched the MPN for the doctor’s name since (as indicated below) the DWC does not list a website address for the terminated ACE American MPN.

In summary:

1. A QME examined a worker and recommended care.
2. A defense attorney instructed a doctor to provide the QME-recommended care.
3. Sedgwick refused to conduct UR or authorize the care because the doctor is not a member of a terminated ACE MPN.
4. Presumably, the injured worker remains untreated.

Trader Joe’s and the defense attorney should all be appalled by the abuse Sedgwick, ACE, and California legislators who endorse MPNs collectively inflicted on this injured worker.

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