Medical Care For The Injured Worker – Part 1

I’m Ed Smith, a Sacramento Workers’ Compensation Lawyer. The workers' compensation system in California mandates doctors to provide evidence-based medical treatment, which is scientifically proven as being effective in treating work-related injuries and illnesses.

There are clear guidelines specifying treatments for injuries with broad details on intensity, duration, and other aspects of the treatment.

California’s evidence-based treatment system has been named as medical treatment utilization schedule (MTUS). Governed by the guidelines of the American College of Occupational and Environmental Medicine's (ACOEM) Practice, MTUS is also enriched by ideas from acupuncture, post-surgery therapy, and mitigation of chronic pain

Disputes are common on the payment authorization for injured or ill workers’ medical care by the claims administrator. These may range from the timeliness of the payment to the amount of payment authorized. Such issues can be sorted out by seeking assistance from the Information and Assistance Officer and taking them up with the claims administrator.

One way to solve issues is to seek an expedited hearing before a workers' compensation administrator. More information on the matter can be obtained from the DWC district officer.

Delay in Claims Processing vs. Urgency

On already settled cases, the guidelines are deemed in place even if the case was closed before the guidelines on the workers' compensation law in 2003 came into being.

A claims administrator begins processing the authorization of medical treatment within one working day after receiving the worker’s claim from the employer if the claim is under investigation.

The maximum amount authorized for treatment when a claim is under investigation is $10,000. In case there is a delay in authorization and the claims administrator does not act within a reasonable time, the matter should be taken up with the supervisor or someone in management.

Another option can be to speak to the claims administrator directly. The aggrieved worker must convincingly cite the laws on the delivery of immediate medical treatment. The worker can urge the concerned officials for faster authorization even if the claim is under verification.

Limits on Treatment

Curbs exist on certain types of treatments. One of the imposed limits is that injuries from 2004 onward will have permission for twenty-four chiropractic sessions, twenty-four physical therapy meetings, and twenty-four occupational therapy episodes. An exception can be made only when the claims manager allows more visits and recommends that the worker have the surgery they need. On top of this, postsurgical physical care and/or medicine is included in this package.

Duration of Treatment

Technically, a worker is entitled to get treatment as long as it is medically needed. However, there are legal restrictions on some treatments under the premise that the medical treatment must be evidence-based.

The MTUS offers an array of treatments for work-related injuries and illnesses with directives on the span and frequency of the treatment.

In case a treatment exceeds the time period recommended by the MTUS, then the doctor must produce evidence that further treatment is essential and it will benefit the worker.

Review by the Claims Administrator

On all matters relating to treatment, the claims administrator has the right to order a review of any treatment plan mooted by a doctor under a third party.

This process is called utilization review. Claims administrators are legally empowered to run a UR program in order to approve or reject a treatment plan.

The intent of UR is to make sure that a treatment is medically viable and the program by the doctor is concrete enough for approval.

The state has clear rules on how UR must function. If a worker is apprehensive that the UR Company is not fair in its operations, the rules allow them to file a complaint with the DWC.

Disapproval of Treatment Plan

In accessing insurance rights, timelines is critical. As of July 1st, 2013, physicians are authorized to solve all medical treatment disputes through the process of independent medical review.

If a UR rejects or modifies a treatment plan by a physician on the ground that the treatment is not medically necessary, the affected worker can seek a review through IMR.

His or her review petition must accompany a paper with a signed signature that could either deny or modify the requested treatment. In such a case, the worker will soon be issued an unsigned yet filled out IMR document along with an envelope. They can sign the form and initiate the IMR process.

Treatment Done but Payment Denied

If a worker has already received medical treatment and had problems in recovering the costs, including non-release of funds by the administrator, then the cost of the treatment must be borne by the worker. But this situation can be addressed beforehand if the worker seeks the intervention of the doctor and claims administrator.

Medical Provider Network

Injured workers are provided access to medical treatment through a number of methods. There is MPN as a group of healthcare providers arranged by the employer's insurance company and authorized by the DWC's administrative supervisor to treat injured workers.

MPN has specialists who can treat work-related injuries. It will also have expert doctors who handle general areas of medicine. An injured worker will have access to them according to their needs.

However, an employer’s provision of an MPN facility does not stop a worker from using the services of a pre-designated personal doctor whose service he may have used previously before the injury took place.

Healthcare organizations (HCO) are also managed by the DWC to deliver medical care to injured workers. But the rules will vary as to how an employer can retain an HCO or an MPN for medical care to address the needs of their workers.

Primary Treating Physician (PTP)

A major part of the responsibility lies with a primary treating physician (PTP) with regard to the treatment of the injured or ill workers. In normal circumstances, an employer will use the service of a PTP for the first 30 days. Thereafter, citing special circumstances, a worker can seek treatment from a pre-designated physician or a medical group.  

If a doctor makes a recommendation that a worker needs extended treatment beyond 30 days, in such cases the worker can also cordially and rightfully request a physician of his or her own choice.

Pre-designating a Personal Doctor

As previously mentioned, a worker gets the right to pre-designate a personal doctor of medicine (M.D.) or a doctor of osteopathy (D.O.). But the following conditions must be fulfilled:

  • The injured worker must forward a written request to the employer seeking a pre-designated personal physician or medical group on a date prior to the date of injury for which treatment has been requested. The request must carry the physician's name and address.
  • The employee must have an appropriate medical insurance coverage under a plan, policy, or fund. The coverage must take care of non-occupational injuries or illnesses on the date of injury.
  • The consent of the employee's own physician or medical institution or group must be obtained prior to pre-designating them for treating the injured worker.

The relevant DWC form for fundamentally pre-designating a specific doctor can be downloaded from the DWC website.

Treatment by a Personal Chiropractor

If an employer or employer's insurer has no MPN, then the worker can change the treating physician to a personal chiropractor or an acupuncturist in order to receive alternative treatment for the work-related injury or illness.

To implement such a change, the worker must provide to the employer the name and business address of the personal chiropractor or the acupuncturist in writing prior to the injury or illness.

The form is called a notice of personal chiropractor or personal acupuncturist. It must be submitted after the expiry of the first 30 days of medical treatment guided by the claims administrator.

However, if a worker has sustained an injury on or after Jan. 1st, 2004, he cannot make a chiropractor his own physician, especially after 24 chiropractic visits have been completed.

After 24 chiropractic visits, if there is a need to continue the treatment, a new physician must be chosen, but he or she should not be a chiropractor.

Cap on Chiropractic Visits

The cap of 24 chiropractic visits is significant. That does not apply to injuries that have occurred before Jan. 1st, 2004. Furthermore, the cap will be redundant if the employer recommends additional visits in writing. The cap also does not exclude the worker from asking for or utilizing postsurgical physical medicine and rehabilitation services.

Sacramento Workers’ Compensation Lawyer

I’m Ed Smith, a Sacramento Workers’ Compensation Lawyer. Were you or a loved one hurt on the job and need an experienced workers’ compensation lawyer to help you claim disability benefits? Please reach out to me right away at (916) 921-6400 or (800) 404-5400 for compassionate, free and friendly advice. You can also find me online on my website, AutoAccident.com.

I have been practicing law in California since 1982, helping injured people and their families recover from accidents. My valued client’s reviews are posted on Google+, Yelp, and Avvo.

I am pleased to be recognized by the Million Dollar Advocates for my work winning verdicts and settlements worth one million dollars or more for my clients.

Read more, including summaries of my past Verdicts and Settlements, on AutoAccident.com.

:br rey [cs 1566] mb 11.29.17

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