The Medical Provider Network (MPN) system in California is out of whack — to the point that it breeds the kind of improper payment denials that make it impossible not to ask if claims administrators are simply taking advantage of the chaos.

Case in point: Third-Party Administrator (TPA) Sedgwick Claims Management Services, acting on behalf of Lowe’s, recently denied payment to a physician for Medical-Legal services based on MPN non-participation. Of course, MPNs do not apply to Medical-Legal services. And even if they did, Lowe’s does not currently maintain an approved MPN.

Is Sedgwick serious? Are Sedgwick adjusters so overwhelmed by the convoluted MPN system that they can make a mistake like this honestly? Or does Sedgwick simply rely on the fact that providers can’t navigate the MPN system, or effectively appeal improper MPN-based denials?

Sedgwick False MPN Payment Denial: Lowes Home Centers, LLC

There is no excuse for Sedgwick not to know that MPNs are never applicable to bills for Medical-Legal services. Yet somehow, Sedgwick still cites MPN non-participation to deny reimbursement to Qualified Medical Evaluators (QMEs) and Agreed Medical Evaluators (AMEs).

Moreover, Sedgwick cites non-participation in MPNs that are no longer approved and active.

It’s like the TPA isn’t even trying to put so much as a thin veneer of legitimacy on these blatantly invalid denials, like the one below. Sedgwick denied the physician payment for evaluating an employee of Lowe’s, citing MPN non-participation.

Lo(we’s) and behold, the only Lowe’s MPN is terminated. Of course, even if Lowe’s currently maintained an approved MPN, it would have no relevance to a bill for Medical-Legal services. But this is Sedgwick, and this is the California MPN system, and nothing makes sense — because if it did, TPAs wouldn’t be able to use the MPN system as cover for stiffing doctors.

Unless the doctor submits a Second Review appeal within 90 days of receipt of the payment denial, California law allows Sedgwick/Lowe’s to keep the falsely denied payment. However, Sedgwick routinely, improperly denies Second Review appeals as duplicate bills; in 2022, Sedgwick denied over 9,153 valid Second Review appeals from daisyBill clients as duplicate bills.

If Sedgwick pulls the “duplicate bill” nonsense in this case, the provider will have to expend the time and resources necessary to compile a request for IBR, including the $180 IBR filing fee. Fortunately, IBR precedent suggests the DWC will accept the dispute and that Maximus, the DWC’s IBR proxy, will rule in the doctor’s favor.

In addition to wondering if Sedgwick knows better re: MPNs and Medical-Legal bills, we also have to wonder:

• Does Sedgwick charge Lowe’s for maintaining the terminated MPN listed above?
• Does Sedgwick also take a percentage of the unwarranted “MPN savings” from the doctors caring for its clients injured workers?

Sedgwick Habitual Med-Legal Pattern

As noted above, this is not the first (or even the second) time Sedgwick has cited MPN non-participation to deny payment for Medical-Legal services. daisyNews has reported on this habit of Sedgwick’s twice before (and we know the good folks at Sedgwick read this blog).

IBR: Sedgwick Ordered to Pay QME $20k+ for False Med-Legal Denial

Sedgwick Stiffs QME With False MPN Denial (Again)

Whether Sedgwick comes by its incompetence honestly, or just figures that providers don’t have the time, energy, and resources to fight back against invalid MPN-based denials, one thing is clear: MPNs give claims administrators a way to save themselves and/or their clients a great deal of money, taken straight from provider’s pockets.

It is extremely unlikely that even a single injured worker has ever benefited from the MPN system — but certain entities are benefitting handsomely.

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