Stephanie Leras
Director, Program Management Administration
Tom Kerr (TK): Nearly 20 years ago, California established a Medical Provider Network (MPN) provision to control state workers’ compensation costs. In today’s podcast, Stephanie Leras, Director, Coventry Network Program Management, joins me to discuss the California MPN regulations and current trends associated with it.
So, let’s get started. Can you describe what the California MPN is and how it works?
Stephanie Leras (SL): Absolutely. The California MPN is a certified program that’s approved by the California Division of Workers’ Compensation, and this program enables an employer to channel care to physicians and facilities with expertise in treating work‑related injuries.
This medical provider network allows for channeling for the life of a claim. And without an MPN or another certified type of network, you can only channel care for 30 days. So, it’s really important that any payer within the state of California has a certified network.
The MPN has been around since 2004, and it’s had an immensely positive effect on cost containment because all MPN providers have a contractual relationship with the CA MPN, and it’s had a great affect on the injured employees’ return to work. This is because MPNs are networks that have providers with expertise in workers’ compensation, and the only other certified network type in the state of California is a health care organization (HCO). HCOs are still in existence, but they only allow for channeling for 180 days.
So most major payers in the state of California use an MPN because it allows you to channel that claim for the life of the injury.
TK: And what do you mean by channeling?
SL: That means directing care. So, an injured employee is required to treat with an MPN provider, rather than seeking treatment from another doctor that they might just find through the phonebook.
TK: Got it. Thank you. So, what are the main requirements of an MPN?
SL: The MPN has specific requirements regarding specialty and access because the goal of an MPN network is to get the injured employee to a doctor that has expertise in treating work‑related injuries that can see them in a timely manner.
So, in order to get your MPN certified, you must meet requirements regarding primary treating doctors. You must have three within 15 miles of the injured employee’s home or workplace. You must have an urgent care center and a hospital within those 15 miles. And then you must have specialists that are most commonly used to treat workers’ compensation injuries within 30 miles.
And, additionally, you must have a medical access assistant who is available to help the injured employee set an appointment with an MPN provider. And that appointment must be made within certain timeframes as well. An initial appointment must be made within three days and a specialty appointment must happen within 20 days.
Again, you want that injured employee seen and treated by an expert doctor in workers’ compensation who knows how to get that injured employee back to work as quickly as possible.
The last requirement that we haven’t yet talked about is requirements for physicians. Physicians, or their authorized representative, must sign an MPN provider acknowledgment. That provider acknowledgment is a contractual document which the doctor signs indicating that he or she wishes to be part of the MPN and will abide by MPN regulatory requirements.
And this, again, is for the injured employee’s protection because you know that that MPN provider is going to treat that injured employee within the guidelines established by the state, specifically, for utilization review and the timeframes required to get an injured employee seen and treated.
TK: And what are some of the current trends you’re seeing regarding California MPNs?
SL: We’ve seen a lot of trends, recently. And it all goes back to the reform that started in 2014. In 2014, there was a major workers’ compensation reform in California that definitely impacted MPNs. And the goal there was to institute things like the medical access assistant to help injured employees get appointments with MPN doctors as well as the MPN acknowledgement, which helped a physician provider understand not only which MPNs they were participating in, but reaffirmed that they wanted to participate in those MPNs.
So, it added some additional criteria to really put more teeth into the MPN. Additional reforms happened in 2021 that further clarified which types of providers could be in MPNs, and there were some changes that happened there as far as what type of contracted providers an MPN could have.
In the midst of all of those changes, there was some confusion that arose that these were legislative changes. The Division of Workers’ Compensation, which manages MPNs, then had to impose MPN regulations around them. And sometimes the way those were instituted was confusing to the payer community and was not always transparent.
Additional concerns have been raised recently by physicians in the state of California regarding the California fee schedule. An additional contractual relations discount that are taken on top of that fee schedule which they feel, at times, impacts their practice negatively.
The Division of Workers’ Compensation has responded to the payer concerns on MPN application process and what is appropriate and isn’t appropriate for MPN composition, and the physician’s concerns regarding reimbursement. It has instituted a series of stakeholder meetings so that we can all come together, talk about these concerns and, hopefully, brainstorm and propose some additional solutions. And the goal is to do this with the Division of Workers’ Compensation rather than at a legislative level, to see what we can do to work together to make the process better.
It’s been a very positive experience thus far, and we’ve already seen some process improvements from the Division of Workers’ Compensation, which enables us to understand the MPN application process and get MPN applications approved more quickly.
TK: What are the different types of California MPN programs available?
SL: We offer a variety of MPN programs. We have standard MPN networks, which means that we maintain them on behalf of our MPN clients, and that’s for those organizations that don’t want or need the upkeep of the MPN program.
All of our standard MPN programs are statewide, but they differ in size and composition to cater to our differing clients’ needs. Our largest MPN, the Select MPN, is for those organizations that are adding employers consistently and therefore want maximum choice. Our Primary MPN is a subset of the Select MPN, and the providers in Primary must meet additional performance factors in order to be included.
Both our Select and Primary contain numerous specialists to treat more complex workers’ compensation conditions — things like asbestos exposure — so we have a lot of faculty plans with specialists that have expertise in the more complex conditions.
Our final option is our Coventry MPN, which has an emphasis on occupational medicine clinics and the most commonly used workers’ compensation specialty. That MPN is often chosen by organizations with employees engaged in manual labor that have the types of injuries that we most commonly associate with workers’ compensation claims, such as back issues, sprains and strains, carpal tunnel, and those type of things.
Our final MPN option is our custom MPNs. We have over 50 distinct custom MPNs. These are proprietary MPNs specific to our client, so either a TPA insurer or an employer. And these custom MPNs enable an organization to select the appropriate specialties and geographic coverage that meet their needs.
So, Coventry provides the analytical and regulatory support to help these clients build these custom MPNs that will meet the MPN standards imposed by the state of California, as well as we have an online tool which enables clients to manage these custom MPNs monthly.
And our online tool enables our clients to see their custom MPN, what it looks like, where they have regulatory gaps, and the providers available to fill those gaps, so you not only build a network that meets the needs of your employees, but you ensure that that MPN network continues to meet those needs on an ongoing basis.
TK: Do different payers have different needs and goals when it comes to an MPN?
SL: Absolutely. And, depending on an organization’s size, structure, and location, as well as their goals regarding performance, savings and network configuration, their MPNs will differ.
An employer that owns a construction company in Central California is going to have different needs than an employer that does research and their employees are exposed to chemicals. There are all kinds of different types of industries, and our ability to help that organization build a custom MPN which has the specialties and geographic coverage that are needed by them is what really enable them to see the best outcomes in return to work and overall claims outcome as far as the reduction of permanent disability.
TK: What is on the horizon for MPNs and, specifically, Enlyte innovations?
SL: Well, I’ve already touched on our network customization tool, which is constantly being looked at for additional enhancements. And we get so much information back from our clients on what enhancements would be useful.
Having over 50 custom MPNs, we have all kinds of clients that use this tool on a monthly basis, and it can help us in ensuring that it is continuing to improve for them. What the tool does is enables you to see where you have network gaps and enables you to fill those gaps. It also will show you where you have a medical group, where you have some providers in network and others that maybe aren’t in network that you might want to consider adding because you already direct injured employees to that medical group.
But going forward, what we’re looking at is enabling you to see as a custom MPN where you are spending money at out‑of‑network providers, so you already know that you’re spending money there, you might want to consider adding those providers to your medical provider network.
We also have a tech‑enabled provider portal for provider education and communication that is being constantly enhanced. We see our best outcomes when we have partnerships with our clients and our providers. And we need to make sure that we’re not only giving providers the opportunity to check bill status, but also utilize us for other industry related information and educational opportunities. So, provider networking engagement is huge.
TK: OK. So, what makes the Enlyte MPN different?
SL: I think the essential difference is that we have a core group of people here at Enlyte — myself, our network director, and our government affairs liaison — who not only live in the state but have been working in workers’ compensation within the state for the past 25 years. This has enabled us to build relationships with the payer community, with the lobbyist community, with the state and the Division of Workers’ Compensation as well as other state agencies, and really understand where we’ve been, keep our pulse, and help direct where we’re going.
Our network director for recruitment and development can tell you what freeway to take in Southern California, at what time of day, and where physicians’ offices need to be located based on an injured employee’s location on that intricate web of freeways and traffic. So, he understands more than just geographic location — such as the state’s requirements that you must have and know a provider within 15 miles — he understands where that office would need to be located in order for that injured employee to actually get there. And you just can’t fake that kind of familiarity. You need that in order to build networks that are really meaningful for employers in the state
So, we’re a leader in custom MPN and certification based on that expertise. We have more custom MPNs than any other network as well as our network customization tool, that allows an employer to look at their network monthly and make sure that their MPN network is performing at its optimum level.
Your network is only as good as it is today. You can build the best network in the world, but if you don’t maintain it, it’s not going to be the best network tomorrow. Really, at our core also is our contracts. We have the largest directly contracted workers’ compensation network.
We not only have relationships with our clients, but we have relationships with our providers and they are the ones providing the treatment within the MPN network. And that’s essential. We’re all partners and we’re all working to make this a more advantageous environment for the injured employee.
TK: So, what are the advantages of using the Enlyte family of businesses?
SL: I think the biggest advantage to using the Enlyte family of businesses is the expertise and the integration we bring given our full suite of services. And what I mean by that is we have clinical services, utilization, bill review, networks, data analytics, MCOs. It enables us to bring a fully integrated perspective to a client and understand the product from all of its different nuances; whether that be what needs to be done in clinical, or the regulatory requirements in a particular state, or the limitations, or challenges that we have with the physician population should we have shortages in that state.
We’re able to bring all of those perspectives and full market knowledge to our clients and offer them the best comprehensive product that we can. Additionally, we’re constantly looking to improve, looking at additional partners and opportunities which enable us to expand and offer our clients an even better product than we’re able to offer them today.
And we’re looking for opportunities in all of those fields that we just mentioned, whether that be a network, clinical or data analytics opportunity which enables our clients or our providers to have better access to claims payment information, or patient information, for example.
So, having all of those come together really give us a unique opportunity to offer our clients comprehensive solutions where others just can’t do it.