MEDICAL TREATMENT IN THE WORKERS’ COMPENSATION SYSTEM IN CALIFORNIA

Stethoscope on the Cardiogram

 

Prior to a work injury, you can pre-designate your doctor if you fill out the paperwork from your employer's human resources department.  If not, you most likely have to go to the clinic your employer's workers comp carrier has chosen.

If your employer has a Medical Provider Network (MPN - a list of doctors), you can change your doctor at any time as long as the provider is within their network (the workers' comp carrier can give you the link to their list of doctors).     

If employer does not have an MPN, the employer has control over treatment during the first thirty (30) days after the injury.  After that, you can pick any reasonable physician to be your primary treating physician (PTP).

 

Medical treatment in workers’ compensation has an overly complicated process in California; requests by a doctor can take over a month for it to be approved and received by the injured worker.  

 

Below is an explanation of how an injured worker gets medical treatment within the workers ’ compensation system in California.  

 

1. PRIMARY TREATING PHYSICIAN AND THE REQUEST FOR AUTHORIZATION

First, an injured worker goes to their Primary Treating Physician (PTP) and if the PTP believes you need medical treatment, that doctor has to fill out a form called a Request for Authorization (RFA).  

 

2. UTILIZATION REVIEW

The RFA is sent to the claims adjuster at the insurance company.  The Utilization Review department (UR) reviews the RFA and can accept, deny, or delay the RFA.  

 

If the RFA is accepted, the injured worker can get the suggested medical treatment.  

 

3. INDEPENDENT MEDICAL REVIEW

If the RFA is denied or delayed, the insurance company sends an application for Independent Medical Review (IMR) to the injured worker and their attorney.  Redula & Redula LLP automatically appeals every IMR that we receive for our clients.  

 

The application is sent to an independent medical reviewer, a third doctor, who can uphold, overturn, or partially overturn the RFA.   

 

Uphold means the independent medical reviewer believes the treatment is NOT medically necessary or appropriate and the injured worker cannot get the medical treatment.  This decision is good for one-year or until there is a change of circumstances (which would start the process all over again with the PTP).    

 

Overturn means that all the treatment is found to be medically necessary or appropriate.  The injured worker can get the medical treatment.

 

Partial overturn means that some of the treatment is found to be medically necessary or appropriate.  The injured worker can get the IMR approved medical treatment.  

 

As you can see, the steps to get medical treatment can be a long process.  Medical treatment can be reviewed by more than three medical providers before an injured worker can pick up their medication or receive the treatment.  

 

Redula & Redula LLP works to keep the steps going by appealing and following up.  There are time limitations and processes that every injured worker must deal with and this can take, at minimum, over thirty (30) days before receiving the medical treatment.  



 

Redula & Redula LLP helps injured workers who live and work in Monterey, San Benito and Santa Cruz counties.  We help injured workers apply for workers’ compensation benefits after work injuries - specific injuries, cumulative trauma (repetitive work injuries), psychiatric injuries, death benefits cases, subsequent injuries benefits trust fund cases (SIBTF), slip and falls, carpal tunnel syndrome.    

 

Salinas, Monterey, Greenfield, King City, Soledad, Seaside, Marina, Del Rey Oaks, Carmel-by-the-Sea, Carmel, Carmel Valley, Gonzales, Pacific Grove, Sand City, Boronda, Pebble Beach, Spreckels, Santa Cruz, Aptos, Watsonville, Soquel, Capitola, Scotts Valley, Ben Lomond, San Juan Bautista, Hollister, Aromas