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Workers’ Compensation: What to Do if Your Medical Treatment is not Authorized

What to Do if Your Medical Treatment is not Authorized

The workers’ compensation system in California requires doctors to provide only evidence-based treatments. This means a medical professional must only choose a treatment that has been scientifically proven to relieve or cure workplace injuries or illnesses.

These treatments are included within a set of guidelines related to, among other things:

  1. Which treatments are appropriate for what types of injuries.
  2. How often the treatment must be administered (frequency).
  3. What the extent of treatment (intensity) should be.
  4. For how long the treatment should be provided (duration).

When the Claims Administrator has Neither Accepted nor Denied a Claim

California workers’ compensation law requires a claims administrator to authorize appropriate medical treatment within a day after the injured worker has filed a claim form with their employer (even while the claim is under investigation). The maximum amount that can be released for treatment while the worker’s claim is being investigated is $10,000.

In case the claims administration fails to authorize the treatment within one working day, the worker should inform his or her supervisor, another person in management, or the claims administration regarding the law that permits immediate medical treatment.

Workers have a right to ask for the medical care to be authorized within a day, while they await a decision on their claim.

What is a UR (Utilization Review)?

Utilization Review or UR is the program that the claims administrator will use to ensure that the treatment an injured worker receives is medically necessary. The law requires all claims administrators to have a UR program.

They will use the program to determine whether or not to authorize the medical treatment that has been recommended by the injured worker’s physician. Under the UR program, the claims administrator could hire a third party to review the treatment plan recommended by the injured worker’s doctor.

How Long Can Injured Workers Receive Treatment?

Injured workers under the California workers’ comp law can receive medical care for as long as it is medically necessary. But certain types of treatments are limited by law.

The Medical Treatment Utilization Schedule (MTUS) lists treatments that are scientifically proven to relieve or cure workplace injuries or illnesses. The Schedule also deals with the frequency and length of the treatment, among other issues.

If the treatment advised by the injured worker’s physician goes beyond what the MTUS has recommended, the physician must use additional scientific evidence to show that the treatment is necessary and effective.

When the Doctor’s Recommended Treatment is Not Approved

Injured workers must adhere to specific timelines, or they stand to lose some of their rights. The law mandates (as of July 1st, 2013) that disputes related to medical treatment for an injury of any date will be resolved by doctors through an IMR process (Independent Medical Review).

If the doctor’s request for treatment has been modified or denied under UR, the injured worker has a right to ask for a review of such decision through IMR.

In addition to a written determination letter informing denial or modification of the workers’ requested medical treatment, they will also receive a completed but unsigned IMR form along with an addressed envelope. If the worker disagrees with the UR decision, he or she should sign and submit this form to initiate the IMR process.

If Workers were Treated but the Claims Administrator Will Not Pay for it

The injured worker will most likely not be required to pay in this situation. This problem must be worked out between the claims administrator and the doctor.

If Workers Disagree with the Doctor’s Report on their Injury

The worker can ask for a medical evaluation with a doctor called the QME (Qualified Medical Evaluator) in the following situations:

  • The worker’s claim was denied or delayed, and they require a medical evaluation to determine if the claim will be payable.
  • The workers want to find out if they have some kind of permanent disability, or if they would require future medical treatment.
  • The workers disagree with what the doctor has said about their injuries, work restrictions, or temporary disability status.

If the workers are legally represented, their lawyer and the claims administrator could agree on a physician to examine the injuries. The workers can receive a list of QMEs (from which they can make a choice).

To get this list, they should complete the form QME 105 and send it to the DWC Medical Unit. The DWC Medical Unit will send the list of three QMEs within 20 working days to the worker and the insurance company. The workers will then have 10 days to choose a QME from the given list, schedule an appointment, and inform the insurance company which QME they have selected.

If Workers Disagree with the QME’s Report

Workers will have only limited time to decide whether they agree with the report of the QME or if they require more information. If they disagree with the report, they should preferably have a competent and successful California workers’ compensation attorney with whom they can discuss their legal options.

If they believe that the QME’s report contains factual errors, they can request for a factual correction by filing a request within 30 days. The claims administrator could also request for a factual correction of the QME’s report.

Once the QME receives a request for making factual corrections, they must file a supplementary report with the Disability Evaluation Unit (DEU) informing whether a factual correction is required for ensuring the report’s accuracy.

Their response should also include whether the factual correction changes the QME’s professional opinion, which is already stated in their medical report.

If they are a member of a union, they may need to meet with a mediator or an ombudsman under the terms of their labor-management agreement or collective bargaining agreement.

Workers’ Compensation Attorneys in Sacramento

I’m Ed Smith, a Sacramento Workers’ Compensation Attorney. Getting medical treatment for your workplace injuries is important. If you or someone you know has been injured at work, call me at 916.921.6400 or 800.404.5400 for free and friendly legal advice. You can also reach me through our contact page at AutoAccident.com

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See our past Verdicts and Settlements here.

What to Do if Your Medical Treatment is not Authorized ~ Sacramento Workers’ Compensation Lawyer

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