California employers pay insurers like The Hartford to ensure that when one of their employees sustains a work injury, the providers who treat them get paid.

Instead, The Hartford makes clumsy attempts to condition treatment authorization on accepting Preferred Provider Organization (PPO) discounts.  

The Hartford authorized psychotherapy treatment for an injured worker. But in the same letter, the insurer declared that only a member of a Prime Health Services PPO is eligible to render that treatment. This condition has no basis in California authorization laws and regulations.  

Providers typically agree to PPO contracts under threat of exclusion from Medical Provider Networks (MPNs), fearing loss of eligibility to treat injured workers. While payers may restrict injured workers from seeking treatment within an MPN (effectively ensuring that treating providers are subject to PPO discounts), California law does not permit payers to condition treatment authorization on MPN or PPO participation.

Ultimately, The Hartford denied payment for unrelated reasons, absurdly citing an irrelevant compensability issue. However, the attempt to condition authorization on PPO membership lays bare the “pay to treat” system that leverages MPNs to force providers into discount contracts.

On multiple occasions, The Hartford has authorized treatment only to deny reimbursement on invalid grounds. Now, this provider must submit a Second Review appeal and potentially endure a lengthy, costly bill dispute process to pursue payment that The Hartford legally guaranteed.

California law treats authorization as a final, immutable guarantee of payment. The Hartford treats authorization as an empty gesture. This is what drives providers out of workers' comp. While California employers have no choice but to keep paying premiums to insurers like The Hartford, providers do not have to treat Hartford-covered workers.

The Hartford Authorizes Treatment

In its letter authorizing psychotherapy treatment, the Hartford explicitly guaranteed payment, stating:

"This certification of treatment assures the appropriate reimbursement will be made for the specific course of treatment stated above."

This closely mirrors the language in California Code of Regulations (CCR) Section 9792.6.1(a), which defines "Authorization" as “...assurance that appropriate reimbursement will be made for an approved specific course of proposed medical treatment.”

Moreover, California Labor Code Section 4610.3 provides that there is no valid reason for a payer to rescind authorization once the provider has rendered the approved treatment. 

Regardless, in the same letter, The Hartford demands that the authorized treatment must be furnished by a Prime Health PPO provider:

"Services must be provided by a Prime Health Services PPO provider."

The Hartford Skips Straight to “Pay to Treat”

Typically, in order to maintain membership in MPNs, providers must accept PPO discounts. Those discounts are then leased, sold, and otherwise shared with various payers, bill review services, and other entities (Prime Health Services is a…prime example).

This “pay to treat” arrangement undermines state fee schedules and systematically drives down real-world reimbursement rates. As a result, daisyData show that the providers in our system collectively receive about 83% of fee schedule rates for treating injured workers.

What makes The Hartford's authorization letter remarkable is that it appears to bypass the MPN part entirely, going straight to the PPO mechanism. The letter does not condition reimbursement on MPN membership (which would also be baseless, but still vaguely in tune with the principle that payers can restrict injured workers to MPNs). Instead, it conditions reimbursement on PPO participation, demanding that the provider hold a private discount contract with a revenue-extraction entity before The Hartford will honor a payment guarantee it has already made.

By this logic, a provider who is a confirmed MPN member but does not hold a Prime Health Services PPO contract has, per The Hartford's authorization letter, forfeited any right to payment.

The Hartford Denies Payment

Despite most definitely authorizing the psychotherapy sessions and granting legal “assurance” of appropriate reimbursement, The Hartford denied payment.

In response to the provider’s bill, The Hartford issued the Explanation of Review below, stating:

“PAYMENT IS BEING WITHHELD PENDING FURTHER INVESTIGATION OF COMPENSABILITY OR TREATMENT.”

The Hartford’s compensability reasoning is invalid on its face (the injury occurred in 2019), but rendered downright absurd by one simple fact: The Hartford has paid this practice on multiple occasions for treatment of this exact injury, both before and after issuing this denial.

The Hartford's Authorizations Are Worthless

A provider who obtained written authorization, rendered treatment that The Hartford deemed medically necessary, and submitted a compliant bill must now file a Second Review appeal to pursue reimbursement.

Previously, The Hartford tried to condition authorization on MPN membership, yet denied payment despite the fact that the provider was in fact an MPN member. In this case, The Hartford sought to condition authorization on PPO participation, then denied payment for spurious compensability reasons.

In both cases (and others), The Hartford failed to abide by a simple, straightforward principle of California law: authorization guarantees payment, regardless of MPNs, PPOs, compensability, or anything else The Hartford flings at the wall.

Providers can only assume that The Hartford's authorizations are an empty promise.

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