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Workers' Compensation Medical Claim

Do you have questions about a workers’ compensation medical claim? Do you understand the Medical Provider Network or how to choose a treatment doctor? Our Sacramento Workers’ Compensation Attorneys have worked on thousands of workers’ compensation medical claims. Our lawyers can guide an injured worker through a Utilization Review and an Independent Medical Review. Please call one of our Sacramento Workers’ Compensation Attorneys today if you have any questions regarding your workers’ compensation medical claim.  

What is a Medical Provider Network? 

A Medical Provider Network is a list of doctors authorized by an employer's workers' compensation insurance to treat injured workers. Every Medical Provider Network has a list of doctors who specialize in work-related injuries and doctors who specialize in general medicine. 

Your employer has the right to choose the physician you see for your initial medical claim evaluation and for the first 30 days after your injury. They will choose this doctor from their Medical Provider Network. After 30 days, you can choose a different doctor to treat you as long as they are listed in the Medical Provider Network. 

There are exceptions to this requirement. For example, if prior to your injury, your employer allowed you to designate your personal doctor as your medical provider in the case of a work-related injury, you could see that doctor if you are injured.

Medical Provider Network doctors are paid by your employer's workers' compensation insurance and might lean towards saving the insurance company money. However, all Medical Provider Networks are required to continuously review their quality of care, employee performance, facilities, costs, and utilization of services. 

If you feel the Medical Provider Network doctor treating you is not following the minimum standards or you have questions regarding your medical claim, you should contact a Sacramento workers' compensation attorney.

How do you choose a doctor in a Medical Provider Network?

As stated above, 30 days after you are injured, you can choose a different doctor for your medical claim as long as they are part of the Medical Provider Network. If your employer is a part of a Medical Provider Network, you generally see the doctors in the network.

There are many factors you should consider when choosing a doctor to treat your workers' compensation injury. One of the most important factors is the doctor’s experience writing reports and communicating your medical claim with the workers’ compensation attorney and the insurance company. If the doctor you choose cannot effectively write reports related to the workers' compensation process and your medical claim, then your case is at a considerable disadvantage.

Our Sacramento workers' compensation attorneys highly recommend checking online doctor reviews. However, avoid focusing on the overall star rating and instead read the comments. This will help you get a feel for what the doctor is like and see if that doctor is the right fit for you and your medical claim. Don't discount a doctor if he or she was rated poorly for being late or unsatisfactory bedside manner.

It is imperative you chose the doctor who will treat your injury and effectively write the reports you need to receive the benefits you deserve. If you need help with your medical claim, contact a Sacramento Workers' Compensation Attorney. They know many providers in the area and can help you choose the right one.

What are the Medical Treatment Guidelines?

When you are injured at work, you are entitled to the reasonable and necessary medical treatment you need to treat a work-related injury. The treatment you receive is based on guidelines set by the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines. 

The guidelines are recommendations of generally accepted practices and are deemed scientifically proven to treat or cure your work-related injury. These guidelines include information related to how often and how long the evidence-based treatment should be given to resolve your medical claim. 

Your doctor may prescribe treatment outside the Medical Treatment Guidelines for your medical claim. In that case, your doctor must provide evidence to show that treatment is essential for your recovery. The treatment plan for your medical claim will then be reviewed through a process known as a Utilization Review. 

Contact a Sacramento Workers’ Compensation Attorney if you have questions about your workers' compensation medical claim or Medical Treatment Guidelines.

What is the Utilization Review process?

A Utilization Review is a process used to determine whether the treatment prescribed by your doctor to treat or cure your work-related injury is medically appropriate. 

Your doctor will submit your treatment plan and a request for authorization to your workers' compensation insurance. Your employer's workers' compensation insurance will hire a third party to complete the review and examine your treatment plan. After submitting a request for authorization, the insurance company has five business days to complete the Utilization Review. A judge can review requests for treatment if no decision is made within five days. 

The doctor completing your Utilization Review will never examine you in person but will review the documents your doctor has sent and makes a decision based on defined standards of care. This is why it’s important you have a doctor who is skilled at writing effective reports for workers' compensation claims. 

The Utilization Review decision will be sent to you, your doctor, and the insurance company. The decision could range from outright denial of the treatment requested to modifications of the treatment requested. If your treatment is denied, you can appeal the decision and start the next phase of the medical claim process. This is called an Independent Medical Review. If you have questions about the Utilization Review process, don’t hesitate to contact a Sacramento Workers' Compensation Attorney today.

What is an Independent Medical Review?

If there is a disagreement over the appropriate care of an injured worker, an Independent Medical Review will help make the final decision. An Independent Medical Review is a medical claim appeal of the Utilization Review decision and was created to avoid costly legal hearings. 

The California Department of Insurance contracts with a company called Maximus Federal Inc. This company appoints neutral medical experts to complete Independent Medical Reviews. They make decisions on whether medical treatment is necessary on a case-by-case basis. To request an Independent Medical Review, you must complete an Independent Medical Review application form and have a copy of your Utilization Review decision letter within 30 days of acquiring the decision. 

No matter where you are in the process of a workers’ compensation medical claim, a Sacramento Workers’ Compensation Attorney can guide you. If you have medical claim questions regarding Medical Provider Networks, choosing a doctor, medical treatment guidelines, Utilization Reviews, or Independent Medical Reviews, don’t hesitate to reach out. Our workers’ compensation lawyers will provide you with a consultation, free of charge.