The law for California workers’ compensation states claims administrators are required to authorize payment for medical care when it is reasonably needed to relieve or cure the effects of an injury. In 2003 and 2004 laws were put into place that this care was to follow scientifically based medical advice. Also, under the California workers’ comp laws; if an injury is a work-related incident, it is illegal for a physician to bill a worker for the care of the injury.

Types of Medical Care

When you suffer an injury while working at your job, you are entitled to reasonable medical treatment to relieve or cure work-related illnesses and injuries. The doctors must be made aware that your injury or illness is work-related, and they are required to treat you per the guidelines under the Medical Treatment Utilization Schedule. Your treatments will only be approved if they follow this schedule.

  • Medical Treatment Utilization Schedule

The medical treatment utilization schedule is set of regulations in title 8 of the California Code of Regulations section 9792.20 through 9792.23 that holds medical treatment guidelines and rules for what is reasonable and necessary medical care for your injury or illness. The Schedule is based on principles of evidence-based medicine. This basis means all treatment decisions have to follow the recommendations supported by the best available evidence.

Your employer or the administrator of the insurance carrier handling workers’ compensation claims are required under California law to have what is called a utilization review program. This program will be used to determine whether or not your injury or illness is eligible for the medical care recommended by your doctor.

  • Utilization Review

The utilization review is a process your employer or the administrator of the insurance carrier uses to figure out if your treatment is medically necessary. They are required by law to have this program as it uses guidelines set by the state whether or not they should accept your claim and cover the medical care your doctor prescribes.

The placement of the Utilization Review was put there by the State of California due to the increasing number of workers’ comp claims that were filled falsely. Doctors had been found to prescribe treatments not medically necessary for employees claiming they needed medical care for on-the-job injury and employees were dragging out their disability to avoid having to return to the job. Therefore, this review system is in place to verify your injury and the medical care prescribed by your physician.

The utilization schedule in California details treatments scientifically proven to relieve or cure work-related illnesses or injuries. The plan sets out procedures that are proven effective for specific injuries, how often the treatments should be administered, and the extent of any other medical care needed along with other medical details.

What Type of Medical Care is Provided by Workers’ Compensation?

Workers' comp is a state-mandated program and provides you payments by law from your employer when you experience a work-related injury. The program is designed to cover a broad range of injuries, but there are limits. Your employer may be allowed to test you for drugs and alcohol after an accident, and if proven you were under the influence of either, they can deny you benefits. These benefits can also be denied if your injury is self-inflicted, or where you were violating company policy. The key for coverage though is the injury to be covered must occur at your workplace and a result from a duty you were performing for your employer.

California workers' compensation law states workers' comp medical care includes integrated care, fee schedules, pharmacy costs, medical access, guides and guidelines, treatment protocols, and quality of care measurements. The quality-of-care-measurements assess your health outcomes in terms of patient satisfaction and physical recovery.

Payments from Workers’ Comp are generally modest and will cover:

  • Your replacement income
  • Compensation for injuries deemed permanent
  • Medical care for your illness or injury
  • Cost for you to retrain for another job
  • Benefits to your survivors should your injury be fatal

One point to remember is that if you collect workers’ compensation benefits, you cannot sue your employer. These benefits also do not cover your pain and suffering associated with an injury or illness. Wage replacement is generally two-thirds of your average wage, but there will be a fixed maximum amount. A plus to this benefit is that it will not be taxed money, and should begin after you have missed a few days of work due to your illness or injury.

What Injuries are Covered Under Medical Care?

An on-the-job injury is an injury that occurs while you are performing a duty for your employer or completing your routine responsibilities as an employee. Injuries that happen at your workplace can be classified as a ‘work-related’ injury. These injuries can also occur in company-owned vehicles or other locations as long as you are doing an activity connected to employment. These activities could include social events held by your employer even though not on company-owned property.

Injuries that have happened as a result of ‘horseplay’ can be compensable under workers’ comp; however, they are looked at on an individual basis depending on the circumstances of the event. Other injuries medical care will cover can have happened in the cafeteria or other company-owned property or at events sponsored by your employer. There is also an exception to injuries occurring while under the influence of alcohol if your employer provided the drink at a work-sponsored event.

Can You Use Your Regular Physician?

In order to be allowed to use your regular physician, you are required to predesignate them before you are injured. If you have completed this designation before filing a workers’ comp claim, you will be allowed to receive treatments for work-related injuries immediately after you’ve been injured or you suspect a work-related illness.

  • Predesignation

The process of predesignating your personal physician is to advise your employer you want to use your physician to treat you for a work-related injury should one occur. You are allowed to predesignate your personal doctor, or doctor of osteopathy as long as your employer offers group health coverage. This doctor is permitted to treat you as long as they have treated you in the past and have your medical records. This doctor must also agree to care for your work-related injuries or illnesses in writing prior to any on-the-job illness or injury happens.

What if Your Employer Uses a Medical Provider Network?

A Medical Provider Network (MPN) is a group of physicians and other health care providers your employer has selected to treat injured employees. This group is required to be state approved by the Division of Workers’ Compensation. Medical Provider Networks are made up of a mix of doctors who specialize in work-related illnesses and injuries. These healthcare providers have expertise in general areas of medicine. The claims administrator with the insurance carrier is required to provide you with a list of the MPN doctors near you. You are able to select another doctor with the MPN  after your first appointment.

What if Your Employer Uses a Healthcare Organization?

A Healthcare Organization is a certified organization by the Division of Workers’ Compensation and gives managed medical care to injured workers. Health Care Organizations (HCO) are required to have health care providers with an understanding of the workers’ compensation system as well as occupational health care. When you choose a health care provider for your medical care, they will coordinate all of your medical care for your work-related injury and work with your employer to get you back to the job.

What will Your Medical Care be Without HCO, MPN, or a Predesignation?

If you have been injured at work and need medical care, but your employer does not have an HCO, an MPN and you have not predesignated your physician, the insurance carrier can select your medical care physician. The claims administrator with the insurance carrier will choose the medical care you receive for the first thirty days after you’ve notified your employer of an injury. After thirty days, you can choose a different physician or medical facility within a reasonable geographic area.

You can give your employer the address and name of a personal acupuncturist or chiropractor in writing before an injury or illness happens. If this note is in place after an injury occurs, you will be allowed to transfer your care to them after the first thirty days of treatments. Once you have completed twenty-four chiropractic visits, you cannot use your personal chiropractic as your personal doctor.

What if You do not Agree with Medical Care Benefits?

You may not agree with the medical care benefits being issued through the claims administrator with workers’ comp insurance company. There may be a point where you disagree with the reports regarding your condition given out by your doctor. These disagreements may relate to severity, symptoms, your abilities to function with the injury or illness or any other medical report the doctor gives the insurance carrier regarding your injury or illness.

If this disagreement comes up during your work-related injury treatment, you may need to be evaluated by a qualified medical evaluator. These evaluators must be qualified physicians who are able to meet additional educational and licensing requirements. They are required to pass a test and participate in continued education classes regarding the workers’ compensation evaluation process. Talk with Workers Compensation Attorney Law Firm about working with the claims administrator to help you find a doctor that is able to resolve your medical disputes. When you both agree on this physician, they are known as an agreed medical evaluator.

  • Agreed Medical Evaluator

With the help of Workers Compensation Attorney Law Firm, you can obtain an agreed medical evaluator. This physician is one that both you and the claims administrator can agree on to perform a medical evaluation to resolve the dispute.

Can Workers’ Compensation Deny Medical Care?

Medical care is one of the primary benefits provided by workers’ compensation. This benefit is also one that is often denied in part or in whole by the workers’ compensation system. Most states require your employer to pay your medical care until workers’ comp makes a decision on whether or not or injury will be accepted or denied under their system. If your claim is approved, you will continue to receive care with your employer paying the cost.

If your claim is denied, you can continue treatments at your expense and later ask the insurance carrier to pay-back these expenses when and if your denial is overturned through the appeal process. Speak with your medical doctor as they may agree to treat you on what is called a lien basis. A lien basis means that they agree to wait until your denial is appealed and will take the costs of your treatments out of the recovery you receive from workers’ comp. Another option is to check if your state has a temporary disability insurance program where you may be eligible to apply for short-term benefits to cover some of your out-of-pocket costs.

  • Short-Term Disability Insurance Program

California requires employers to give their employees SDI ( short-term disability insurance). This program is also called temporary disability insurance (TDI). These programs provide you with part of your lost wages if you have to leave work for more than a few days due to an illness or injury. This program also covers you if you have to leave work due to pregnancy or recovery from childbirth.

Common Reasons Medical Care is Denied

Insurance carriers and your employer will look for ways to deny your claim for workers' comp. The reason has to be a valid one as you are protected by law to the entitlement of these benefits. There are common, valid reasons that can cancel workers' comp benefits:

  • The injury is not work-related

Many times an employer assumes an injury happened outside the workplace, or that you were misbehaving when the accident occurred. Some employers even attempt to prove the injury or illness doesn’t qualify as a workers' comp incident. If this happens with your claim, you will need to gather as much as evidence as possible to prove your claim.

Witnesses would be a good place to start if anyone witnessed the accident which caused your injury, or an authority to prove your work environment is responsible for an illness. You will also want to gather all medical records and contact a workers’ comp attorney. Choose an attorney with experience in workers’ comp law. Workers Compensation Attorney Law Firm is able to work with you if you’ve been denied an on-the-job injury claim.

  • Claim filed after you left the job

An insurance carrier generally denies a claim if you’ve filed after you’ve been fired, laid off or quit from the job where the injury happened. You may have a valid reason for filing late such as you reported while you were still working, or the injury happened after you gave notice, but before you actually left the job. There are times an employer will fire an employee in retaliation of filing a workers’ comp claim, which is an illegal act and you will need an attorney to help you gain the benefits you’re entitled.

  • Missed filing deadline

If you have been injured on the job, you are required to report the injury as soon as possible. You should advise your employer immediately after you are hurt, and then file a workers’ compensation claim. If you miss the deadline to file set up by your state’s guidelines, the insurance carrier can deny your claim. Some states will overlook the claim filing date as long as you notify your employer right away, but it is to your advantage not to miss either deadline.

  • The injury does not qualify under state guidelines

Each state has restrictions on which injuries, cumulative trauma, or psychological condition they will accept as workers’ comp claims. Insurance carriers have been known to deny claims for an illness caused by long-term stress at the job, or your injuries might not meet workers’ comp requirements as being severe enough.

Your Options if Medical Care is Denied by Workers’ Comp

Do not give up if the insurance carrier denies your medical care benefits. If you work in California, your medical care is a benefit you deserve if you’ve been injured at your workplace. This medical care; however, is controlled by an insurance company, and your medical fate ends up in the hands of the insurance carrier’s reviewer.

The doctor from the insurance company does not know you, and most likely doesn’t have all your medical files. This process is the Utilization Review and allows for the insurance company to choose an outside physician to determine if your claim will be accepted or not. This doctor will decide if the treatments prescribed by your physician should be authorized under workers’ comp benefits. The doctor does not even have to be licensed in California to have this decision power over your claim.

If your claim is denied, your recourse is to appeal the decision to an IMR (Independent Medical Review). MAXIMUS is the company in California who will review your case. Just like the Utilization Review doctor, the Independent Medical Review doctor will decide your fate, and also does not have to be licensed in California, nor have access to your full medical file. This irony means that your chances of the IMR doctor accepting your claim are not much better than the UR’s doctor acceptance.

  • Independent Medical Review

The State of California contracts with the company, MAXIMUS to review all your reports and records in order to decide if your denial from workers’ comp should be upheld or not. The reports and records given to MAXIMUS are from the insurance company. It would be in your best interest to contact Workers Compensation Attorney Law Firm to receive their help in providing the IMR with additional medical information from your doctor. You and your attorney cannot create any new evidence on your condition; however, you can ask your doctor to write a medical report that addresses any issues raised by the UR denial in support of your appeal.

The Institute of California’s Workers’ Compensation has found that more than 90% of the IMR’s decisions agree with those of the UR’s doctor. Receiving a denial is not the end of the road for you; however, you have the right to appeal the IMR determination. Your rights give you the option to appeal a denial made under a conflict of interest, fraud, or mistake of fact. Workers Compensation Attorney Law Firm can help you with your appeal and make sure you receive the benefits you need to heal from your injury.

Can I go to Court to Receive Medical Care?

There are ‘reform’ laws in place that have been designed to keep judges and doctors out of the medical making decisions. It is believed that doctors are to make medical decisions and resolve medical disputes. At one point it was possible to receive a medical opinion and then have a judge decide which opinion presented the most relevant facts; however, now it is determined on ‘evidence-based’ standards.

If your workers’ comp claim for medical care is denied, it is in your best interest to speak with Workers Compensation Attorney Law firm. Ensuring the reviewers of your case have all the correct information and records to decide whether or not your claim can be accepted is vital to you receiving the medical care you deserve.

Contact a Workers’ Compensation Attorney Near Me

Call our Los Angeles work injury lawyer at 310-956-4277 to discuss the status of your workers’ comp claim if you are in the Los Angeles Area. The workers' compensation program has strict guidelines to follow, and they can help you through this challenging time to get you the medical care you deserve and need to heal from an on-the-job injury.