Delos Insurance Company
Employer Frequently Asked Questions
about the MPN
Q: Are MPNs mandatory by State Law?
A: No. A workers' compensation insurance carrier, self-insured employer, Joint Powers Authority, or the State of California MAY choose to create an MPN. There is no requirement to do so. Each eligible payer entity may decide for its own organization if it wants to establish and use an MPN for their employees' occupational medical care.
Q: My workers' compensation carrier uses an MPN. Can I as an employer elect not to participate in the MPN?
A: No. All employers within the policy are required to use the MPN for medical treatment for work injuries or illnesses.
Q: Do I as an employer have to do anything to enroll my employees in the MPN? Is there any eligibility waiting period?
A: No. By virtue of the MPN becoming effective, all of your employees are automatically enrolled immediately upon the effective date of the MPN, or later on their first day of employment. Just as they are immediately covered for workers' compensation benefits under state law the moment they begin working for you, they are also immediately covered under the provisions of the MPN upon commencement of employment.
Q: I have been informed about the designation of a Primary Acute and Non-Acute Initial Treating Physician or Clinic. What if I prefer to use another treating physician or facility for my employees' initial medical treatment?
A: You may elect to use any other physician or clinic, as long as that provider is within the network . Please notify us at the Call Center if you have another preference. If you wish to use a medical provider that is not currently in the MPN, please contact the MPN Call Center at 866-536-2853 and we will make an attempt to add the provider into the network.
Q: How do I find out information about other medical providers near my work location?
A: By clicking on the “Provider Lookup” link, you will be directed to another site that will ask you for specific criteria, including the physician specialty and zip code. Enter the information, and the site will display a list of participating providers, and a map providing directions where to find each one.
Q: Can I obtain a full listing of all medical providers in the MPN?
A: Yes. A pre-generated directory of the full provider listing can be obtained online. The link is on the Provider Lookup Page.
Q: Must chiropractors and acupuncturists be included in our MPN network?
A: An adequate number and type of physicians and providers, as described in Labor Code §3209.3 and §3209.5 are necessary to treat common workplace injuries and illnesses based on the type of occupation and industry in which the Labor Code sections include acupuncturists and chiropractors.
Q: My employee sustained a serious on-the-job injury that required emergency treatment with a provider who is not within the MPN. Is this covered treatment?
A: Yes. Initial medical treatment necessary to treat an emergency, defined as “health care services for a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place the patient's health in serious jeopardy” is covered by workers' compensation state law, even if the initial provider is not a member of the MPN. Once the employee is stabilized, however, the employee will likely be re-directed into the MPN.
Q: What if my policy expires or I obtain insurance with another insurance carrier? What happens to the medical care for injured workers under the Delos Insurance Company Insurance Company/TMC MPN?
A: Medical care for these injured workers will continue to be furnished under the provisions of the Delos Insurance Company/TMC Medical Provider Network, for the life of the claim. If the injured employee sustains a new injury covered by another subsequent insurance carrier, the care for the new injury as covered by the other insurance carrier would be provided under the conditions of that insurance company's MPN.
Q: What about claims under investigation? For employees whose medical expense liability is limited to $10,000 until the claim is accepted or denied, does medical treatment for these delayed claims still remain within the MPN?
A: Yes, any such medical treatment would be subject to the provisions of the MPN, and must remain within the MPN.
Q: What if an employee pre-designates a personal treating physician? Is he or she still required to treat within the MPN?
A: An employee who notifies the employer in writing prior to an injury that he or she pre-designates a specific provider to furnish medical treatment for an industrial injury, is allowed to treat outside the MPN. This pre-designation must include the consent of the pre-designated treating physician, and is not allowed if your firm does not offer a group health plan or insurance. Despite the fact that the pre-designated treating physician may not be within the MPN, that provider must still comply with medical reporting requirements and follow ACOEM treatment guidelines in accordance with state law.
Q: My employee wants to change treating doctors to another physician within the MPN. Is this allowed?
A: Yes. At any time your employee may change treating physicians, as long as that provider is within the MPN. The law states that “the selection by the injured employee of a treating physician and any subsequent physician shall be based on the physician's specialty or recognized expertise in treating the particular injury or condition in question.” There is currently no restriction on the number of treating physician changes the employee is allowed to make.
Q: What if my employee has not pre-designated a treating physician and refuses to obtain medical treatment within the MPN?
A: The law is clear about an employee's responsibilities and rights concerning Medical Provider Networks. Employees have the right to change treating physicians within the MPN, but unauthorized medical treatment obtained from a doctor outside the MPN is not covered or paid by AARLA. While certain circumstances may arise where treatment outside the MPN can be authorized by AARLA on a case-by-case basis (if for example the MPN does not contain a physician who can provide treatment as approved by AARLA), the rule is, if an employee refuses to treat within the MPN, then this medical treatment is unauthorized, self-procured, and ultimately the financial responsibility of the employee. Likewise, lost time disability indemnity payments can only be authorized by a treating physician within the MPN. AARLA will not pay indemnity disability benefits that arise from the opinion of a treating physician who is outside the MPN.
Q: What if an employee has a bona fide dispute about the diagnosis or treatment recommended by the MPN physician? What legal remedies are available?
A: An employee disputing the diagnosis or treatment prescribed by the MPN physician can obtain a second opinion from a physician within the MPN network . Employees who further dispute the second opinion may likewise obtain a third opinion within the MPN network . Further details about this process are discussed in the MPN Employee Handbook .
Q: Can an employee obtain a fourth opinion? What about the QME (Qualified Medical Examiner) process?
A: Employees who still dispute the findings of the second and third opinion physicians are entitled to an Independent Medical Review ( IMR ). See the procedure for this process located in the Notice Concerning Independent Medical Reviews . Ultimately, if the IMR physician disputes the diagnosis or treatment prescribed by the treating physician, the employee has the right to obtain the disputed treatment or diagnostic service by any physician, inside or outside of the MPN.
The employee is still entitled to a panel Qualified Medical Examination (QME), for standard workers' compensation issues under dispute such as the permanent and stationary level of the employee, nature and extent of permanent disability, ability of the employee to return to the pre-injury occupation, or nature and extent of future medical treatment.
Q: What if a treating physician within the MPN is terminated from the network? Can medical treatment be continued with the provider after termination of the contract?
A: The Continuity of Care policy explains in detail how in some cases, care will be continued with the terminated provider, and in some cases, care will be transferred to an alternative provider within the MPN. See the policy for further details.
Q: What is the policy concerning employees who already have an existing workers' compensation claim and are still treating for their injury? Do they have to change treating physicians within the MPN?
A: In many cases, employees receiving medical treatment from providers who are not members of the MPN will be re-directed and care transferred to a provider within the MPN. There are some exceptions, however, as provided by law. See the Transfer of Care policy for further details.
Q: What do I have to do as an employer in order to implement the MPN?
