We’ve argued that MPNs are mostly a drag on the workers’ compensation system. But as some employers demonstrate, they don’t have to be.

When employers use MPNs to maintain a community of trusted health care providers for their workers, the benefits are apparent. But when insurers, bill review, and PPO entities use MPNs to bully providers into accepting pay cuts for treating workers, the harm is undeniable.

Several examples highlight opposite ends of the MPN spectrum.

MPN Abuse

In theory, MPNs help ensure quality care and contain costs, by allowing employers to establish a preferred circle of providers. In truth, the composition of MPNs is more often dictated by insurers and other payer-side entities, rather than employers. This is to the detriment of providers, patients, and employers.

For example:

The mysterious arrangement between SCIF and Anthem: SCIF, an insurer, maintains an MPN on behalf of several employers. As we detailed recently, to be considered for SCIF’s MPN, providers must also join the Anthem Network of Providers — which confiscates a variable percentage of the provider’s reimbursement.

It’s unlikely that the employers have any idea how SCIF populates the MPN, let alone any say in the matter. Is this simply an opportunity for SCIF and Anthem to profit at providers’ expense?

Zurich’s inaccessible access agents: Zurich also maintains MPNs on behalf of employers. Like many claims administrators, Zurich fails to furnish workers and providers with the MPN resources mandated by state regulations, such as Medical Access Agents (MAA).

On behalf of providers, DaisyBill agents have spent countless hours trying to chase down Zurich MAAs for MPN information. No Zurich MAA has ever returned our many, many calls. Not once. What hope does a provider or patient have to get necessary MPN information out of Zurich, if DaisyBill can’t?

Sedgwick and Zurich’s MPN hoarding: Some insurers maintain multiple, sometimes dozens of MPNs, and may add or remove providers seemingly at a whim. In fact, providers themselves often have no idea which MPNs they belong to. In practice, a provider may be part of a given MPN on Tuesday, only to be removed Wednesday and denied reimbursement on Thursday.

Sedgwick Claims Management currently maintains no less than 29 active MPNs. At one point, Sedgwick maintained 75 separate MPNs. Even more stunning, Sedgwick has terminated 241 MPNs. How can California legislators expect providers to manage Sedgwick’s 270 total MPNs?

Source: Department of Industrial Relations Open Data Portal: List of Approved MPNs

As the table below shows, Zurich also maintains a slew of MPNs:

Source: Department of Industrial Relations Open Data Portal: List of Approved MPNs

Employers Holdings’ Conditional Authorization: To skirt authorization rules, Employers (a payer, not an actual employer), included an MPN caveat in the language of their responses to provider Requests for Authorization (RFA). In blatant defiance of state regulations, Employers claimed they could rescind authorization if the provider was later found not to be a member of the Employers Holdings MPN.

Prime Health’s MPN and PPO conflation: Prime Health sent at least one provider an MPN agreement and a PPO agreement concurrently, and continues to describe PPOs as “under the umbrella of” MPNs. Understandably, this can leave providers confused as to the distinction, and implies that MPN membership is conditional on PPO membership.

As far as cost control goes — supposedly the raison d'etre of MPNs —  multiple analyses reveal that employers save somewhere between very little and less than nothing by utilizing MPNs.

How MPNs SHOULD Work

With all the above acknowledged, it’s not all schemes and scams in the world of California MPNs. Every so often, we find a glimmer of what’s possible when employers actively manage their own MPNs, with the interests of their employees and providers in mind.

Case in point: the City and County of San Francisco (CCSF), a self-insured municipal employer.

Together with the city’s Transportation Agency, CCSF maintains a small MPN to treat municipal workers. Its reputation with those workers is positive; fire and police unions granted CCSF commendations for their handling of members’ healthcare needs. CCSF also has a reputation among providers for prompt payment, attentiveness to provider needs, and a fair-minded approach to disputes.

The satisfaction of both patients and providers in what CCSF calls their “small, boutique network” is evident — and made possible by CCSF’s view of MPN providers as assets to be valued, not marks to be exploited.

When CCSF’s own bill review, EK Health, attempted to apply a baseless PPO reduction to a provider’s bill (citing without evidence the provider’s alleged inclusion in a separate Coventry-managed MPN), CCSF moved swiftly to investigate, and ultimately sided with the provider.

Attn: DWC: The MPN “Honor System” Doesn’t Work

It’s heartening to see truly employer-maintained MPNs like CCSF’s. Such MPNs provide a foil to MPNs that are manipulated by the likes of Anthem, Prime Health, Employers Holdings, and other arguably opportunistic entities.  

That acknowledged, the MPN system cannot rely on the honor system.

Patients, providers, and employers can’t afford to sit back and hope that their MPN is managed with their best interests at heart. Far too often, the opposite is the case. It is the state’s responsibility to create and enforce regulations governing the role of MPNs, and prevent abuse by thoughtless profiteers.

Recently, a California bill to create a statewide alternative to MPNs was scuttled right before a hearing to debate its merits. The legislation’s intention was laudable: allow injured workers to choose their own providers. But without warning, the measure was abruptly watered down, as if with a firehose.

The current version calls only for a study of the MPN system, with no changes mandated. It’s possible the original version of the bill may have ended the use of MPNs as tools of manipulation, intimidation, and obfuscation of reimbursement reductions. Unfortunately, we may never know.

We hope California’s Division of Workers’ Compensation, in the absence of strong action by the state legislature, will turn an eye toward curbing MPN abuse.

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