Medical Treatment Basics in Workers' Compensation
Summary of Medical Treatment in the Workers' Compensation System
Medical Treatment "Reasonably Required"The standard in the California workers' compensation system for when treatment shall be provided by the employer is "medical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of his or her injury." That language is taken directly from Labor Code Section 4600. The Labor Code is the set of laws that govern workers' compensation in the State of California. As noted below, what is considered "reasonably required" must be established by your doctor in the form of a Request for Authorization or RFA and must then be approved through the utilization review process, also explained below.
Medical Provider Network (MPN)Treatment must be within your employer’s Medical Provider Network (MPN), unless you have a valid pre-designation signed by your treating doctor prior to your injury date. The employer and their claims administrators get to hand-pick the doctors within their network, so the doctors they select often are located at industrial clinics or otherwise have a loyalty to the insurance company so as to stay on the list. That doesn't mean that all, or even most, of the doctors on the MPN list are bad. However, you want to be a strong advocate for yourself by ensuring your doctor is providing the care you need by establishing the "medical necessity" of any treatment requested.
If you do not care for the initial MPN doctor, you are at liberty to transfer your care to any doctor in the appropriate specialty that is in the employer's MPN.
Request for Authorization (RFA) Required by Your DoctorAny treatment requested by your doctor will need to be placed on a required "Request for Authorization" (RFA) form. On the form, and any attached accompanying documentation, the treating physician is required to refer to the medical guidelines established by the Department of Industrial Relations in explaining why a particular treatment is medically necessary. If the doctor fails to cite the proper guidelines, or leaves out important information requested by the guidelines, it is highly possible the treatment will get denied by the utilization reviewer.
Utilization ReviewUnfortunately, treatment is subject to utilization review where a doctor hired by the insurance company, a doctor you never meet, reviews all treatment requests by the MPN doctor for “medical necessity.” It is important your doctor be familiar with, and cite, the various treatment guidelines to improve your chances of getting treatment authorized.
Independent Medical ReviewIf treatment is denied through the utilization review process, an appeal can be filed, known as Independent Medical Review (IMR). Strict time lines are in place for an appeal to be filed. If treatment is denied, you want to have a discussion with your doctor immediately as to whether the doctor will produce the documentation that may have been missing on the RFA, information that may have resulted in the treatment being denied. You want to make sure your doctor addresses the specific reason or reasons outlined in the utilization review denial in the form of a supplemental report. You then want to make sure the supplemental report, and any other relevant reporting, is forwarded to the Independent Medical Review company. Your doctor also has the option to attempt to have a "peer to peer" conversation with the utilization review doctor to explain why the treatment is medically necessary.
IMR can overturn the utilization review denial. However, if iMR "upholds" the denial, the denial is valid for 1 year. Your doctor can re-request the treatment after 1 year. However, it is important your doctor include in the additional request whatever information may have been missing from the initial request. Otherwise, another denial is likely.