How to get treatment in the workers’ compensation

This blogger greets you again, but with the topic on how to get treatment in the workers’ compensation. When your claim is accepted, the employer is responsible for treatment that is “medically necessary” which means “reasonably required to cure or relieve the injured employee of the effects of his or her injury”. When your claim is denied, you cannot obtain treatment through the workers’ compensation system; instead, you must treat privately at your own costs, but save your receipts in case your case is accepted, at which point you can request reimbursement (no guarantee you will be reimbursed).

When your claim is accepted, you can begin treatment with a workers’ compensation doctor which we call a Primary Treating Physician (PTP). That PTP generally must be in the employer’s Medical Provider Network (MPN) unless your employer does not have an MPN, or you have properly predesignated a workers’ compensation doctor by executing DWC Form 9783 and meeting all the requirements in Labor Code section 4600(d) and definitions in Cal. Code Regs. 9780 (e) and (f).

To locate your MPN, review the initial documents given to you by the insurance company as they will likely contain a website link to the MPN where you can search according to the type of doctor and location you want. Simply ask your adjuster (or your attorney) which doctor you’d like to see (but first, call the doctor and confirm they are accepting new workers’ compensation patients). At that point, the insurance adjuster should authorize treatment with that doctor, send your records to that doctor and you should schedule an appointment with that doctor.

You must be proactive in seeking treatment, do not wait for the doctor to call you. Once treatment begins, the PTP might suggest physical therapy, acupuncture, x-rays or MRIs but that request must be on a specific form called a Request for Authorization (RFA). This form is required. Depending on your type of injury, when you seek treatment, ask the doctor to consider the following items.

Even if the QME does find you are hurt, there must be treatment records for the QME to review and consider, especially when your claim has not been settled with court approval. You must be proactive in seeking treatment, you must ask about a treatment plan. Do not assume the doctor remembers every detail of your case, be friendly and offer a summary during every visit. To request treatment (even Tylenol or any of the treatments listed above) the PTP must fax the insurance company a Request for Authorization (RFA) using DWC Form RFA. This specific form must be used.

The PTP first faxes the RFA to Utilization Review (UR) but UR often denies treatment based on “lack of medical necessity.” However, if the insurance company ignores the RFA for 5-days (sometimes 14-days), you can skip the denial/approval process (UR/IMR) and go right to the judge. That’s why a copy of the RFA with proof it was faxed to the insurance company is important. If you feel treatment was requested but not approved or authorized thus ignored by the insurance company, ask your PTP for a copy of the RFA with proof it was faxed to the insurance company to prove treatment was requested. Maybe you will find out the treatment at issue was never requested. Please recall treatment is controlled solely by your PTP at his or her discretion (not the QME).

QMEs do not control treatment, instead they tell us what body part should be eligible for treatment. Primary Treating Physicians (PTPs) determine appropriateness of specific treatment modalities, and their treatment requests are approved or denied based on the Medical Treatment Utilization Schedule (MTUS) and Utilization Review (UR) and Independent Medical Review (IMR) doctors. It’s an imperfect system. Please recall, workers compensation is a government mandated system.

There must be medical documentation to support the need for treatment requests. For example, if you never complain about your low back pain and there are no specific details documented in your medical records on how it worsened or how treatment has alleviated the problem in the past, then why would a peer review doctor agree to additional treatment? Another example, if you got an injection, and the injection made things worse, or resulted in no improvement (things are the same), then a peer review doctor may not authorize a repeat injection.

When treatment is formally requested and formally authorized, you will receive an authorization letter, sometimes authorizing some or part of the requested treatment. Generally, on the bottom of the authorization letter, there is a specific phone number for certain types of approved treatment. For example, there is generally a phone number just for prescriptions or for durable equipment such as canes, walkers, braces or boots. When you call that specific phone number on the authorization letter, the person you speak with will contact the work comp insurance company to verify the treatment was authorized, then they will arrange for the pickup through the computer system at the desired pharmacy or medical facility. But before you go to that pharmacy, call them to see if their computer system reflects the authorization. In short, no pharmacy card is needed. For more complicated authorized treatments such as surgery, injections or surgical consolations, someone from the insurance company, typically a nurse manager, will contact you to arrange the appointment or your PTP will make a referral to the secondary specialist (this is a slow process, 10x slower than you might expect).

Denials of treatment are an unfortunate aspect of workers’ compensation. You can appeal denied treatment but often they are upheld by the statutory peer review system. To understand why treatment is denied, turn to the “rationale” section of the UR denial or IMR denial. When there is a UR denial, you can appeal the denial to Independent Medical Review (IMR) who is contracted by the Administrative Director of the Department of Industrial Relations. An IMR doctor generally upholds UR denials upward of 90% of the time. See the data in the report published in the following link. See table 9 on p.12 in the following and you will see that in 2023, 89.8% of all UR decisions denying treatment stayed denied. https://www.dir.ca.gov/dwc/IMR/reports/IMR-Annual-Report.pdf.

If you are frustrated with treatment through workers’ compensation, just know in Valdez v. WCAB (2013) 78 CCC 1209, 1216, the California Supreme Court affirmed the Court of Appeal’s decision that Lab. Code § 4616.6 does not prevent employees from seeking treatment at your own expense; meaning you can seek treatment privately and pay for it at your own expense (assuming the doctors will agree to that). But, if you get served with a bill or sent to collections for unpaid treatment, you’re on your own for that. And if your injury worsens through private treatment, the workers’ compensation insurance company is not responsible for that worsening. Hopefully now, you know a little bit more about how treatment works in the workers’ compensation system. It is full of denials and delays, an unfortunate aspect of workers’ compensation. Keep a file of all your papers, your claim being approved, the PTP being authorized to treat you, treatment requests that were approved, copies of MRI reports, etc., and be prepared to reference them to doctors as they could use your help sorting through the thousands of pages that might be in your file.

Mastagni Holstedt attorneys have built a track record of success at trial and on appeal in state and federal courts across California. Founded on attorney-client privilege, we have been assisting police officers, firefighters and the general public for decades in matters ranging from internal discipline and criminal defense to wage and hour, disability and workers’ compensation claims. If agreed upon, our office can file your claim for you, direct you to treatment, give you the best advice and see you through your injury until the end. This blog is for educational purposes only. This is not legal advice. There is no substitute for competent legal advice tailored to your specific circumstance so give us a call at (877) 212-6907 and see how our skilled attorneys can assist you or your organization. I hope you enjoyed reading this. Have a nice day.