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Medical Care, Reimbursement, and Treatment Information

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It is important to keep a client informed of their options and educated about the process. This is especially true for what kind of medical care, medical reimbursement and medical treatment options you might have. The following is general information meant to educate you about the workers’ compensation system as a whole. We would be happy to set up a free initial consultation and case evaluation to discuss and help you with your specific injury and case. You may contact us at any time at (714) 783-2205 as we can answer your specific questions and address your concerns. We are an experienced law firm that has helped thousands of injured employees with their workers’ compensation claims, third-party cases, and personal injury cases.

What Medical Care am I Entitled to For My Work Accident Injury?

The kinds and amount of treatment that is believed to be needed for all the different types of work injuries is being determined by the state Division of Workers’ Compensation (DWC). These guidelines will be scientifically based, nationally recognized, and peer-reviewed as guaranteed by the law of California. Until then, workers’ compensation uses the published guidelines by the American College of Occupational and Environmental Medicine (ACOEM), called “Occupational Medicine Practice Guidelines.” If your injury is not covered by the ACOEM guidelines, your treatment may follow other guidelines as determined by the law at that time.

Will Any of These Guidelines Still Apply if I Have Already Settled My Case?

They may. The accepted treatment guidelines are still considered correct even in cases that settled before the guidelines were added to workers’ compensation law. You can request an expedited hearing before a workers’ compensation administrative law judge if your medical treatment has been denied.

Do Certain Kinds of Treatments have Limits?

Yes, they do. You are limited to a total of 24 physical therapy visits, 24 chiropractic visits, and 24 occupational therapy visits. This is unless the claims administrator authorizes any additional visits.

What Can I Do if I Need Medical Care Now But the Claims Administrator Hasn’t Accepted or Denied My Claim Yet?

To try and avoid this situation, the claims administrator is required by law to authorize medical treatment within one weekday after you file a claim form with your employer. This is true even during the time your claim is being investigated. The amount of treatment is limited at $10,000. Speak to management or your boss if the claims administrator does not authorize treatment right away.

How Long Am I Able to Receive Medical Treatment?

The quick answer is: For as long as it’s medically necessary. The reality is that all treatments are authorized using the guidelines discussed above. If your doctor believes that treatment is necessary beyond the timeframe or quantity authorized in the current guidelines, they then must present evidence of why treatment should be extended. In addition, your doctor’s new treatment plan might be reviewed by a third party hired by the claims administrator. This process is called utilization review (UR). All claims administrators are required by law to have a UR program to decide whether or not to approve treatment recommended by your doctor.

What Are Utilization Reviews?

Utilization review (UR) is what claims administrators use to ensure the medical treatment you are receiving and hope to receive is medically necessary. UR decides whether or not to approve medical treatment recommended by your doctor. If you believe the UR company reviewing your doctor’s plan is not following the rules of California and the workers’ compensation system, you may file a complaint with the DWC (Division of Workers’ Compensation). You also have the right to be seen (on an expedited basis) by a workers’ compensation administrative law judge if there is a dispute over your medical care.

Do I Have to Pay if I Got Treated and The Claims Administrator Won’t Pay for It?

In most situations, the answer is no. This is an issue your doctor or medical team needs to work out with the claims administrator.

I Heard About MPNs, What are They? (Medical Provider Networks)

MPNs are a group of health care providers set up by your employer’s insurance company and approved by the administrative director of the DWC to treat employees who were hurt while working. Each MPN includes a mixture of doctors specializing in work-related injuries and doctors with expertise in each of the general areas of medicine. If your employer is in an MPN, your workers’ compensation medical needs will be taken care of by doctors in the network. This is unless you were eligible to pre-designate your personal doctor and you did so before your injury happened.

What if I Do Not Happen to Like the Doctor in the Medical Provider Network?

The claims administrator is required to give you a full list of eligible MPN doctors. You can change to any of the doctors within the network if you do not like the one you have now.

How and When Can I Pre-Designate My Personal Doctor?

This process allows you to use your personal physician to treat you for a work injury or workplace accident. You need to have done this before you had your job injury. You can pre-designate your personal doctor of medicine or doctor of osteopathy only if all of the following are true:

  • Your employer offers group health coverage;
  • The doctor has treated you in the past and has your medical records;
  • Before the injury, the doctor agreed to treat you for work injuries or job illnesses; and
  • Before the injury, you provided your employer the following in writing:
    • Notice that you want your personal doctor to treat you for a work-related injury or illness; and
    • Your personal doctor’s name and business address.

What If I Happen to Disagree With the MPN Doctor’s Treatment Plan or Diagnosis?

You have two general options for resolving a medical dispute if you are in an MPN. Which option you can choose depends on the situation.

  • The first is if your doctor in the MPN requests treatment for your job accident or work injury that you do agree with but that treatment gets denied during the UR (utilization review), you have the right to be evaluated by a qualified medical evaluator (QME).
  • The second is if you disagree with your MPN doctor about your diagnosis or treatment. In this case, you will not go to a QME. You will have the options of changing to another physician within the MPN or ask for a 2nd and 3rd opinion from a different doctor also in the MPN.
  • If you still disagree, you may request an independent medical review (IMR) to resolve the dispute.

Who Decides What Kind of Work I Can Do While I Recover?

The doctor who is taking care of you is the one who is responsible to explain the following in a medical report:

  • The kind of work you are able to do while you recover from your work accident; and
  • The changes that are needed in your work schedule or assignments.

You, your doctor, your supervisor or employer, and your attorney (if you have elected to have one like the experienced workers’ compensation lawyers at our firm) should review the job description that your doctor has designated for you. If you disagree with the employment plan that your doctor has prepared, you must write to the claims administrator about the disagreement right away.

What If the Claims Administrator Disagrees With My Doctor’s Treatment Plan or Other Medical Issues?

In the case of your claim administrator disagreeing with your doctor, you would probably be asked to see another doctor for a second opinion. This doctor will either be a QME (qualified medical evaluator). If you have an Orange County workers’ compensation attorney, it could be an agreed medical examiner (AME).

This doctor will fully examine you, your recovery so far, your treatment plan, and your injury. They will then write a report giving their professional opinion. If you, your doctor and the claims administrator still cannot resolve your disagreement(s) after you read the report from the QME or AME, you have the option to take your case to the Workers’ Compensation Appeals Board (WCAB).

Why do I need to see a Qualified Medical Examiner (QME)?

For many reasons, you or the claims administrator could disagree with what your doctor reports prescribes and plans for your treatment. A doctor who is qualified and experienced with workers’ compensation has to address those disagreements and medical issues. The Qualified Medical Examiner report (or the AME report if you have legal representation) also helps to determine what benefits you receive. A few examples of what you and the claims administrator could possibly disagree over include:

  • Whether or not you actually need treatment for your work injury;
  • What type of treatment and medical plan is appropriate;
  • Whether or not your injury was actually caused by your work;
  • Whether or not you need to stay home from work to recover; and
  • If you deserve a permanent disability rating.