As daisyNews frequently explains, California's Medical Provider Network (MPN) system accomplishes nothing other than making treatment less accessible for injured workers and turning revenue management into a nightmare for providers.

California employers are forced to fund this MPN dysfunction by purchasing comp coverage from insurers like The Hartford.

The Hartford recently granted authorization to a provider for psychotherapy, but attempted to make that authorization conditional on the provider's MPN membership, a sketchy hedge against reimbursement with no support in California law or regulations.

The Hartford provided an MPN name, but no MPN ID number, despite maintaining multiple MPNs. As it happened, the provider is a member of the applicable MPN. Yet The Hartford denied reimbursement anyway, claiming on its Explanation of Review (EOR) that:

"THE TREATING DOCTOR AND/OR SERVICES RENDERED WERE NOT APPROVED…”

Both rationales are counterfactual. The provider submitted The Hartford’s authorization document with the bill, and daisyNews confirmed their MPN membership by following the verification instructions in that very document.

Now the provider must navigate California's lengthy, costly, and payer-friendly bill dispute process to pursue their rightful reimbursement.

This payment denial is a textbook example of how the MPN system helps drive providers out of the comp system entirely. When payers can leverage (and arguably exploit) MPNs to deny reimbursement for authorized treatment, doctors stop accepting comp patients.

Today’s story is a warning to providers to carefully consider whether it’s worth the hassle to treat workers covered by The Hartford. As the debacle below (and an additional story we’ll explore in tomorrow’s article) demonstrates, this insurer exemplifies what pushes providers out of the system.

Unlike providers, most employers have no option to tap out of workers’ comp; they must continue to pay ever-increasing premiums, along with disability payments for injured employees who struggle to find care in a system that deters provider participation.

The Hartford's Equivocating "Authorization"

California law is clear: authorization is a guarantee of payment that cannot be rescinded once treatment is rendered for any reason, including MPN non-membership.

Regardless, The Hartford authorized psychotherapy treatment, but buried a poison pill in its authorization letter, stating that "services will only be authorized if completed within our MPN, The Hartford Select Network." Conditioning authorization on MPN membership has no basis in California law or regulations.

California Code of Regulations (CCR) Section 9792.6.1(a) defines "Authorization" as "assurance that appropriate reimbursement will be made" for approved treatment. California Labor Code (LAB) Section 4610.3 clarifies that authorization is non-rescindable, even if the provider is ineligible to treat the patient as an MPN non-member.

Treatment authorization is final, MPN or no MPN. The Hartford can’t violate that principle just by claiming, in its authorization letter, that it can.

The Hartford Springs MPN Payment Trap

The California Division of Workers’ Compensation officially lists 99 MPNs where the MPN applicant name includes the word “Hartford.” daisyNews confirmed that the provider in this case is an active member of ‘The Hartford Select Network’ MPN and that the location of the treatment was listed under that MPN.

With a valid authorization and confirmed MPN membership, the provider submitted the bill, attaching the authorization letter. The Hartford denied payment anyway, issuing an EOR with two rationales:

• "THIS SERVICE REQUIRES PRIOR AUTHORIZATION AND NONE WAS IDENTIFIED"
• "REIMBURSEMENT IS BEING WITHHELD AS THE TREATING DOCTOR AND/OR SERVICES RENDERED WERE NOT APPROVED BASED UPON HANDLER REVIEW."

Both denial reasons are untrue.

The Provider Must Dispute the Payment Denial

To pursue the reimbursement The Hartford owes, this provider must now submit a timely Second Review appeal challenging the denial and asking the insurer to reconsider.

The provider did everything right, obtaining authorization, confirming MPN membership, and submitting a compliant bill. The Hartford's response was to issue a demonstrably invalid payment denial and force this provider into full-blown dispute to collect reimbursement, which The Hartford already promised in a legally binding manner.

When a payer can issue a bogus payment denial and force a provider into the appeals process to collect on authorized services, the calculus for treating injured workers becomes impossible to justify. All California providers should, at the very least, hesitate to treat The Hartford injured workers.

Providers don't have to fight the system; they can choose to leave it. The majority of employers have no such alternative.

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