Medical Treatment

Our Sacramento Workers’ Compensation Attorneys are regularly confronted with questions regarding the process of obtaining medical treatment for our clients’ on-the-job injury in California. More specifically, we see questions regarding the types of treatment injured workers are entitled to and the requirements of choosing a treating physician. We also receive many questions about the basics in regards to the medical treatment utilization schedule, the Utilization Review process, and the Independent Medical Review process. In this article, the Sacramento Workers’ Compensation Attorneys will attempt to answer the most pertinent questions related to medical treatment in the California workers’ compensation system. 

CA WC Case Medical Treatment
What kind of medical care are injured employees entitled to in the California workers' compensation system?

The Labor Code provides that an injured employee is entitled to all care "reasonably required" to "cure or relieve" the worker from the effects of an on the job injury. This provision is entitled to be broad and interpreted for the benefit of the employer. For clarification, however, medical treatment that is provided under the Labor Code does not mean free general healthcare, but rather is medical care related to the work-related injury.

Unfortunately, there is a tremendous amount of dispute as to what is considered reasonable and what is considered required. A short explanation of who decides what care is reasonably required and the process for challenging an adverse decision is below.

Can you choose your own medical provider to treat a work-related injury? 

There is a provision in the Labor Code that is not known by most employees, and consequently rarely utilized. However, if you properly predesignated your own physician prior to the injury, you have the legal right to use that physician. Unfortunately, virtually no one does that, and in all honesty for most injured employees would not necessarily be a good idea anyway.

Unless you predesignated a physician, during the first 30 days after your injury, your employer or the insurance adjuster has the legal right to determine who you treat with for your work-related injury. It may feel a bit unjust and like an invasion of your privacy rights, and we agree. Unfortunately, however, that is the law, and most private physicians and hospitals will refuse to treat non-emergency patients when they learn that it is a work-related injury.

After the first 30 days, you do, however, have the right to choose your own treating physician. The right to choose your treating physician is not without limitations. If your employer's workers' compensation carrier has a Medical Provider Network, you are generally required to choose a physician from that network. Some exceptions to the requirement to use that network do exist. The most common of which occurs when there is a lack of qualified physicians in your designated area of need or geographic area. 

When choosing a physician, be very careful about choosing one for the wrong reasons. Ideally, you want a physician that is not only an excellent treater to help you get better as well as a vast working knowledge of the workers' compensation systems so that requests for approval of medical treatment are approved. Unfortunately, some of the best treaters do not know how to write the requests in a way to get the treatment approved, and some of the best writers can be some of the worst actual treaters. Trying to find a balance between a good treater and a good writer can be vital in getting the timely treatment needed for a proper recovery.

What type of treatment for a workers' compensation injury gets approved? 

As you can imagine, there can be many different thoughts on treating a workplace injury. Some traditional, some cutting edge, and some unconventional. What type of treatment can you get for your workers' compensation injury? In short, the legislature has developed a process whereby a "medical treatment utilization schedule" is published. If your treatment is supported by the guidelines within the medical treatment utilization schedule, it will generally be approved. If it is outside those guidelines, or not adequately documented and supported in writing by your treating physician, it will likely be denied.

The medical treatment utilization schedule is intended to be evidence-based, peer-reviewed, and correspondingly based on nationally recognized standards of care. The medical treatment utilization schedule used in California's workers' compensation largely adopts the chapters and guidelines from the American College of Occupational and Environmental Medicine's published guidelines, however specific clinical topics and fields can vary. 

What is the purpose of a Utilization Review within the California workers' compensation system?

As a mechanism to make sure that procedures and treatments requested by an injured employee's physician are within the medical treatment utilization schedule, the legislature has enacted a process called Utilization Review.

Utilization Review is effectively a process where an injured employee's treating physician completes a "Request for Authorization" to an independent physician. In the Request for Authorization, the physician describes the proposed medical treatment and the factual basis in support of the need for that medical treatment. The Request for Authorization is then given to the designated reviewer to either approve or reject the request. Physicians that do not historically work within the workers' compensation system will often struggle to support their requests properly, and as such, employees often find their care delayed. It is one of the primary reasons why selecting a physician that can and will write useful reports in addition to being a good treater is necessary for the implementation of an efficient recovery plan.

How do you "appeal" a Utilization Review that resulted in denied treatment?

Historically, if treatment was not approved, a workers' compensation attorney could file a petition with the workers' compensation appeals board and bring the matter before a workers' compensation judge. However, the law has now changed where that right no longer exists; instead, the avenue to challenge a denial of a utilization review is to request a review under the "Independent Medical Review" process. Under the Independent Medical Review process, the request and decisions are provided to an unknown/undisclosed physician for review. An Independent Medical Review physician never examines the injured employee, and neither can the employee or attorney for the employee ever speak with the reviewing physician. Because of this inability to meet with the reviewing physician, the chances of success on an Independent Medical Review are considered very slim. It emphasizes again why it is essential to find a treating physician who is comfortable and professional in writing through Request for Authorization.

There are many issues that you can be confronted with when obtaining medical treatment for an on-the-job injury in California. If you have questions about receiving medical treatment or your workers’ compensation claim, please do not hesitate to contact one of our Sacramento Workers’ Compensation Attorneys.