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Third-Party Administrator (TPA) Sedgwick Claims Management Services, acting on behalf of ACE American Insurance Company , refused to consider authorizing care recommended by a Qualified Medical Evaluator (QME), and requested by the defense attorney, for an employee of Trader Joe’s .
Why does Sedgwick refuse to conduct Utilization Review (UR) and authorize the treatment? According to the letter from the Sedgwick adjuster, the reason for the denied authorization was that the requesting doctor was not in the appropriate Medical Provider Network (MPN) — an MPN that daisyBill later discovered was terminated .
A reasonable question: once Sedgwick refuses to process a Request for Authorization (RFA), how does California, Sedgwick, ACE, and Traders Joe’s expect the injured worker (or their attorney) to find a doctor eligible to provide the QME-ordered care?
Seemingly, no one cares.
This tale of California MPN chaos clearly demonstrates that even defense attorneys cannot navigate how to access care for injured workers. Effectively, MPNs do not restrict care to a trusted circle of providers, as MPNs were supposedly designed to.
Instead, MPNs slam the brakes on care (and reimbursement for care) at every turn.