By insisting The Hartford owed no payment for authorized treatment provided outside the Medical Provider Network (MPN), The Hartford pooh-poohed a clear-cut California law re: authorization.

What’s more, The Hartford MPN website failed to include “an adequate number of providers” within the mandated reasonable distance from the injured worker’s home or workplace. Another apparent dismissal of California law re: MPNs.

This latest episode exposes (again!) that payers easily ignore California workers’ comp laws. The Hartford’s refusal to honor its authorization and its neglect of MPN requirements is also further evidence of California regulators tacitly allowing payers to ignore the law.

Read on to see how The Hartford simply prances away from its responsibility to reimburse a doctor who provided care to an injured worker that The Hartford authorized.

The Hartford Authorizes Treatment

The injured workers’ Primary Treating Physician (PTP) submitted a Request for Authorization (RFA) form for psychological treatment. As shown below, The Hartford approved the RFA — but The Hartford sent a Utilization Review (UR) decision that demanded the care be provided by a physician in The Hartford MPN.

The Hartford Violates Authorization Laws (via MPN)

The Hartford’s authorization included language inconsistent with California workers’ comp law, claiming “The physician must be listed in our Medical Provider Network.”

Do employers and insurers have the right to maintain an MPN, and send injured workers to providers within that MPN? Broadly, yes. But there are two important laws that The Hartford seemingly chose to ignore (possibly because California regulators tend not to enforce workers’ comp laws):

1. Authorization is either granted or not. Claims administrators cannot place conditions — including that the provider is in the MPN —  on the authorization.
2. The MPN must include the appropriate specialist providers within a certain distance of the injured worker.

In this case, The Hartford violated both of the laws above.

Authorized Is Authorized, Regardless of MPN

California Labor Code Section 4610.3 is beyond clear in stating that employers (or their insurers) cannot rescind authorization for literally any reason. The Labor Code even specifically mentions cases where “the physician who treated the employee was not eligible to treat the injured employee.”

This is further confirmed by a DWC FAQ, which specifically declares MPNs irrelevant to authorization by the employer/insurer’s Utilization Review Organization (URO).

In other words, the treatment is authorized, not the physician providing it. The Hartford cannot grant conditional authorization based on the physician’s inclusion in an MPN, period. And since authorization guarantees payment, whoever provides the authorized treatment is entitled to the appropriate reimbursement — regardless of their inclusion in the MPN.

In this Hartford example, the PTP is not a psychologist and therefore was incapable of providing the requested and authorized treatment. So after obtaining authorization, the PTP referred the injured worker to an appropriate psychological specialist.

But when the specialist submitted the bill for the authorized psychological treatment, The Hartford denied reimbursement based on — wait for it — the specialist not being in the MPN.

The Hartford MPN Search Lists ZERO Psychologists

Even if The Hartford were allowed to rescind authorization for MPN reasons — which they most definitely are not — The Hartford MPN failed to include a psychologist close enough to the injured worker (again, possibly because California regulators do not enforce California workers’ comp laws).

Following the MPN link provided in The Hartford’s authorization, we see that there is no psychologist listed for either the injured worker zip code or the workplace zip code.

California Labor Code Section 4616 is beyond clear in stating that “The provider network shall include an adequate number and type of physicians, as described in Section 3209.3.” In § 3209.3, the good California legislators listed psychologists as a required type of physician that The Hartford must include an “adequate number” in its MPN.

California Code of Regulations (CCR) Section 9767.5(2) mandates that an MPN must include at least three appropriate specialists (based on the kinds of injuries “common” to workers in the industry) “within 60 minutes or 30 miles of each covered employee’s residence or workplace.”

The Sound of The Hartford’s Cloven Hooves

So, in this case, we know five facts:

1. The Hartford agreed with the Requesting Physician that the proposed treatment was medically necessary and appropriate, hence the authorization.
2. The Hartford refused to reimburse the physician for providing authorized treatment to an injured worker.
3. The Hartford MPN fails to list a physician capable of providing the authorized services.
4. The Hartford refuses to compensate a doctor outside the MPN.
5. California regulators tacitly allow payers to ignore California laws, regulations and rules.

These five facts beg the question: HOW is the injured worker supposed to obtain treatment?

Moreover, HOW can California expect providers to treat injured workers, if it means subjecting themselves to this absurdity?

And yes, that is the sound of The Hartford’s cloven hooves dancing, as more free care is provided to an injured worker by a physician that adhered to every relevant California law.

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