What are an injured employee’s rights to medical treatment?
An injured employee’s rights to medical treatment are broad, but getting that treatment can be very complicated.
Under California’s workers’ compensation system, medical providers are required to provide “evidence-based medical treatment.” That means they must choose treatments scientifically proven to cure or relieve work-related injuries and illnesses. The specifics of what those treatments include is set forth in complex guidelines that provide details on which treatments are effective for certain injuries. In addition to setting the guidelines for the type of treatments available, it provides for the frequency of the treatment, the intensity of the treatment, the duration or length of treatment, and similar items.
In an effort to make more consistent decisions, California has opted to use a medical treatment utilization schedule (MTUS). The MTUS includes guidelines (for specific body regions) from the American College of Occupational and Environmental Medicine’s Practice Guidelines. Additionally, it has adopted guidelines for acupuncture, as well as for chronic pain and therapy after surgery.
If your medical treatment has been denied, a Sacramento Workers’ Compensation Attorney can request an expedited hearing before a workers’ compensation administrative law judge to determine your rights to medical treatment.
What are an injured employee’s rights to medical treatment when the claims administrator hasn’t accepted or denied the claim yet, but medical care for an injury is needed now?
An injured employee’s rights to medical treatment are clear in California. The claims administrator is required to authorize medical treatment within one working day after you file a claim form with your employer, even while your claim is being investigated. However, the amount of treatment is limited (while being investigated) to $10,000.
If the medical treatment is not authorized right away, you should speak with a Sacramento Workers’ Compensation Attorney immediately to compel the administrator to authorize treatment.
Is there a limit on an injured employee’s rights to medical treatment?
An injured employee’s rights to medical treatment are not unlimited. The specific rights vary dramatically based on the date of the injury and what kind of treatment you are seeking, as the legislature continues to change the law. To determine if your rights to medical treatment are limited, you should contact a Sacramento Workers’ Compensation Attorney.
For example, if your date of injury is in 2004 or later, you are limited to a total of 24 chiropractic visits, 24 physical therapy visits, and 24 occupational therapy visits, unless the claims administrator authorizes additional visits or you have recently had surgery and need postsurgical physical medicine.
How long does an injured employee’s rights to medical treatment last?
It is often stated that an injured employee’s rights to medical treatment lasts for as long as it is medically necessary. Unfortunately, that is not the case. Some treatments are limited by law, and the medical treatment and injured employee’s treatment must be evidence-based.
As a starting point, the MTUS outlines treatments that are recognized as scientifically proven to cure or relieve work-related injuries and illnesses. The MTUS also includes details as to how often the treatment is given, and for how long. If an injured employee’s medical provider wants to provide treatment that goes beyond what is recommended by the MTUS, your medical doctor may potentially do so, but must first use other evidence to show the treatment is necessary and will be effective.
Additionally, if there is a dispute regarding an injured employee’s rights to medical treatment, their doctor’s treatment plan may 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. They use UR to decide whether or not to approve treatment recommended by your doctor.
A utilization review is the program claims administrator’s method to decide whether or not to approve medical treatment recommended by your doctor. There are specific rules and requirements as to how a utilization review must be conducted. If an injured employee believes the utilization review company reviewing your doctor’s plan is not following those rules, a Sacramento Workers’ Compensation Attorney can file a complaint with the Department of Workers Compensation.
If you agree with the treatment requested by your doctor and the treatment is denied after being reviewed through the utilization review process, and your date of injury is on or after Jan. 1, 2013, the dispute will be resolved through the independent medical review process.
How are an injured employee’s rights to medical treatment impacted by a medical provider network?
An injured employee’s rights to medical treatment can be dramatically impacted if the employer’s insurance company participates in a medical provider network (MPN). A MPN is a group of health care providers set up by your employer’s insurance company to treat workers injured on the job. Ideally, each MPN includes a mix of doctors who claim to specialize in work-related injuries and doctors who claim an expertise in general areas of medicine. If your employer is in an MPN, unfortunately your workers’ compensation medical needs have to be handled by doctors in the network—unless you were eligible to predesignate your personal doctor and did so before your injury happened.
Generally speaking, to predesignate your personal doctor, you have to tell your employer you want your personal physician to treat you for a work injury. If done so before injured, an employee can predesignate their personal doctor of medicine (M.D.) or doctor of osteopathy (D.O.) if the following conditions are met:
A written notice predesignating the employee’s medical group or personal doctor is given to the employer in writing prior to the date of injury for which treatment is sought and the notice includes the physician’s name and address;
The employee has healthcare coverage for non-occupational injuries or illnesses on the date of injury in a plan, policy, or fund; and
The employee’s personal physician or medical group agrees to be predesignated prior to the dates of injury.
There are forms to assist employees in predestinating a personal physician.
What are an injured employee’s rights to medical treatment if they disagree with the mpn doctor’s treatment plan?
Although cumbersome, injured employee’s rights to permanent disability and/or to medical treatment still exist if they disagree with their MPN doctor about their treatment. An injured employee can change to another physician on the MPN list. An injured employee can also ask for a 2nd and 3rd opinion from different MPN doctors. If the injured employee still disagrees, the injured employee’s rights to medical treatment can be reviewed by an Independent Medical Reviewer.