Praetorian Insurance Company
Employee Frequently Asked Questions
about the MPN
Q: Do I as an employee have to do anything to enroll in the MPN? Is there any eligibility waiting period?
A: No. By virtue of the MPN becoming effective, all employees are automatically enrolled immediately upon the effective date of the MPN, or later on their first day of employment. Just as you are immediately covered for workers' compensation benefits under state law the moment you begin working for your employer, you are also immediately covered under the provisions of the MPN upon commencement of employment.
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. Upon request, we will provide your employer free of charge with a full list of providers, including all specialties, participating within the MPN. Let your employer know if you to have a copy provided.
Q: What if I sustain a serious on-the-job injury that requires 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 your initial condition stabilizes, however, you will likely be re-directed into the MPN.
Q: What if my employer questions my injury, and the claim is 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 I want to pre-designate 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 employer 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: I want to change treating doctors to another physician within the MPN. Is this allowed?
A: Yes. At any time you 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 you are allowed to make, as long as the physicians are within the network.
Q: What if I have not pre-designated a treating physician and I simply don't wish to obtain medical treatment within the MPN?
A: The law is clear about your responsibilities and rights as an employee 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 you refuse to treat within the MPN, then this medical treatment is unauthorized, self-procured, and ultimately YOUR financial responsibility. Likewise, lost time disability indemnity payments can only be authorized by a treating physician within the MPN. AARLA will not pay you any indemnity disability benefits that arise from the opinion of a treating physician who is outside the MPN.
Q: What if I have 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 I 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, you have the right to obtain the disputed treatment or diagnostic service by any physician, inside or outside of the MPN.
You are still entitled to a panel Qualified Medical Examination (QME), for standard workers' compensation issues under dispute such as the permanent and stationary level, nature and extent of permanent disability, ability 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 if I already have an ongoing workers' compensation claim? What is the policy concerning individuals 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: Whom do I contact if I have any further questions about this MPN process?
A: Contact the MPN Call Center if you have any questions about the Praetorian Insurance Company/TMC Medical Provider Network at 866-536-2853.
