Understanding the interplay between Requests for Authorization (RFAs) and Medical Provider Networks (MPNs) is critical to collecting payment.
Frequently Asked Questions
Q: I received RFA authorization, but payment was denied due to not being in the MPN or the ‘Approved Network’. Is this allowed?
A: This is absolutely not allowed. Authorization guarantees payment.
Q: How can I tell which providers are in a given MPN?
A: DaisyBill’s searchable MPN database provides links to the MPN website, when available. Using that link, you can manually check whether a specific provider is listed as part of an MPN. But in general, there is a shocking absence of verifiable information concerning MPNs. In many cases, the resources available to the provider make it impossible to definitively establish whether a provider is included in an MPN.
Q: What, exactly, is an MPN?
A: A Medical Provider Network, or MPN, is a list of providers established by the employer to restrict an injured employee’s choice of providers for the care guaranteed by Labor Code 4600. Read more here.
Explanation
As a general rule, if an employee receives unauthorized care from a provider not included in their employer’s MPN, the employer or insurer is not liable to pay the bills for that care. However, there is an exception.
The employer is always liable for payment when the provider receives authorization, whether or not the provider is in the MPN. Per Labor Code 4610, “an employer that authorizes medical treatment shall not rescind or modify that authorization after the medical treatment has been provided based on that authorization for any reason, including, but not limited to, the employer’s subsequent determination that the physician who treated the employee was not eligible to treat that injured employee.”
Remember: RFAs are mandatory, and authorization guarantees payment.
When the requesting provider is not an MPN physician, a claims administrator may return an RFA without approving it. If the claims administrator does approve the requested treatment, the approval guarantees payment regardless of the MPN status of the requesting physician.
Additional Information
Article 2.3 of the California Labor Code, which contains the legislature’s laws governing MPNs
DaisyBill Resources
Blog Post: Introducing Our Searchable MPN Spreadsheet
Webinar: Understanding Medical Provider Networks
DaisyBill Solutions
DaisyWizard Searchable MPN Database
DaisyBill’s Revenue Cycle Management software features a built-in MPN selection tool that allows you to quickly attach an approved MPN to a specific patient injury and verify which providers are in the MPN.
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