The Medical Provider Network (MPN) system in California is so chaotic, even the adjusters can’t keep up.

For example: Third-Party Administrator (TPA) Sedgwick Claims Management Services, acting on behalf of ACE American Insurance, recently denied payment for treatment of a Trader Joe’s employee. The denial reason cited was non-participation in an MPN. The twist? After daisyBill pressed the Sedgwick adjuster to identify the MPN in question, we ultimately discovered the ACE American MPN was terminated.

This followed several phone calls and a conversation with the Sedgwick adjuster, who couldn’t even provide the ID number for the MPN cited to deny payment — let alone realize that the MPN no longer exists.

If the adjusters, whose entire job is to determine whether a doctor should be paid, can’t keep the MPNs straight, what chance do providers and injured workers have?

Sedgwick/ACE False MPN Denial: Trader Joe’s

In the EOR below, Sedgwick denied payment for the treatment of a Trader Joe’s employee due to MPN non-participation, claiming “SERVICE WAS PERFORMED BY PROVIDER OUTSIDE THE CLIENT’S MPN NETWORK.”

Many insurers maintain multiple MPNs for different employer clients. This makes it even more difficult to determine whether an MPN applies to a given bill. As the Division of Workers’ Compensation (DWC)’s online MPN list shows below, ACE maintains 77 MPNs — nine currently approved, and 68 non-approved MPNs (terminated, withdrawn, or suspended).

To unravel the mystery, daisyBill reached out to the Sedgwick adjuster, who identified the applicable ACE American Insurance MPN as “Sedgwick/Harbor 2 MPN.” The adjuster did not know the MPN ID number, claiming that it had “been a while” since anyone had bothered to ask. Our agent could almost hear the Sedgwick adjuster’s shoulders shrug with the following explanation:

“...I'll be honest, this claim was transferred to me. When we get stuff here, I have to search the MPN and [the doctor’s] name didn't come up. So that's how we started denying this treatment.

It's possible that he used to be in the network and that at some point he didn't meet the standards to be in this network. It could be a few things. That's just kind of how it goes.”

To the surprise of absolutely no one, searching the DWC MPN list revealed that the ACE American Insurance Sedgwick/Harbor 2 MPN is terminated.

This sordid tale gets worse: as we explain in this post, daisyBill later discovered that when the doctor requested authorization for the treatment in question, Sedgwick refused to conduct Utilization Review (UR) because the doctor was not a member of the terminated MPN. The doctor had requested authorization at the direction of the defense attorney, based on the recommendation of a Qualified Medical Evaluator (QME) who had evaluated the Trader Joe’s worker.

If even adjusters can’t figure out whether an MPN applies to a given bill or not, presumably injured workers are being sent to doctors who are not included in the applicable MPN, only to be denied payment. Of course, even if the doctor is included, or the MPN doesn’t exist, claims administrators often deny payment anyway.

And as we’ve explained before, providers can’t rely on appeals to rectify these false denials. Particularly when Sedgwick is involved, a Second Review appeal is often falsely denied as a “duplicate bill.” Moreover, the DWC declares MPN disputes ineligible for Independent Bill Review (IBR), as they do not qualify as fee schedule disputes.

As the Sedgwick adjuster put it: “that’s just kind of how it goes.”

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