Obtaining Medical Care in a Workers’ Compensation Claim

Work Comp Treatment: A Challenging Endeavor

Obtaining medical care in a workers’ compensation claim has become a very challenging endeavor.  This blog entry will explore medical care within the workers’ compensation system and provide some helpful hints so that the injured worker can help his/her doctor in successfully requesting industrial medical care.

In 2013, the legislature in Sacramento increased the permanent disability benefits workers were entitled to.  In order to off-set these increased permanent disability benefits, the workers’ compensation laws were changed to make it harder for workers to get medical care.

Presently, before the worker can get any medical treatment, the primary treating physician (PTP) must fill out a request for authorization (RFA) describing the type of care being requested and justifying the care using a new system called evidence based medicine.  Evidence based medicine requires the doctor to tell the insurance company how the care will “benefit” the patient.  The main criteria for describing treatment benefits is a positive impact on the worker’s activities of daily living (ADLs).  Without this justification, the treatment request is DOA.

What You Should Know

The worker can help the doctor get the care authorized by describing how the treatment has helped him/her.  My suggestion is to bring in a sheet of paper (preferably typed) describing how you feel with and without the treatment.  For example: “When I take my NORCO medication, I can walk for ten blocks before I have to rest.  Without the medication, I can only walk for two blocks.”

The positive impact on the worker’s ADLs can cover all daily activities such as housework, shopping, ability to work, ability to socialize, participate in hobbies – anything that comes to mind.  The following activities are included in the American Medical Association Guides which doctors must adhere to: brushing teeth, eating, combing hair, bathing, going to the bathroom, dressing, writing, typing, ability to sit, hear, speak, stand, walk, climb, taste, smell, grasp, lift, carry, ride public transport, drive, fly in an airplane, have sex, sleep, rest, bend, stoop, squat, reach, kneel, balance, push, pull & twist.  Noticing how the treatment (acupuncture, therapy or medicine) helps you perform these activities and bringing a chart in for the doctor to include in his treatment requests will go a long way towards justifying continued care.

When it comes to medication, the workers’ compensation insurance believes that eventually, the worker should end up taking ZERO medication.  When the worker has a chronic pain condition or has undergone several surgeries – the idea that they can get through the day without any medicine appears to be a cruel way to save the insurance company money that should be spent on appropriate medical care.  The list described above may give your doctor enough “ammunition” to support continued use of medication.  If the medication is “cut off”, then the worker should start a list of how his/her activities have been reduced due to the lack of medicine.

Once the doctor sends in the RFA, the insurance company will send the treatment request to utilization review (UR).  The UR agency is usually an independent contractor hired by the insurance company to tell them if the treatment on the RFA has been justified.  The UR agency has seven days to make the determination.  If the UR company does not make their decision within the seven days, the worker can file for an EXPEDITED HEARING and attempt to justify the requested treatment before a workers’ compensation judge (WCJ).

MAXIMUS Federal Services

If the treatment is authorized, the doctor and the worker will be notified of the positive result and the treatment can begin.  If the treatment is denied, the worker can appeal the denial to Independent Medical Review (IMR).  The State of California has contracted with a national agency – MAXIMUS Federal Services – to conduct all IMRs in the State.  Unfortunately, MAXIMUS is denying 90% of the care that is appealed to them.

The MAXIMUS denial is good for one year – yet – the denial is doctor specific; so, if a different doctor requests the same treatment, the insurance company has to conduct a separate UR review.  Once more, the main justification for medical care under evidence based medicine is a positive impact on the workers ADLs.  If the doctor does not describe this positive impact in the treatment request – there is very little chance for success.

Medical Provider Networks (MPNs)

Another important change in workers’ compensation medical treatment is the advent of Medical Provider Networks (MPNs).  Most insurance companies have MPNs which is a list of doctors the worker is authorized to treat with.  Usually the employer will send the worker to the “company doctor” – an occupational medicine clinic which is able to provide basic care.  The occupational medicine doctor has been told to get the worker back to work asap.  I spoke to a worker recently who was sent back to work two weeks after shoulder surgery; the worker was basically supposed to do one arm work until his shoulder healed.  The employer told the worker there was not “one armed work” available and sent the worker home.  If the company doctor sends the worker back to work, the insurance company does not have to pay any temporary disability while the worker works in pain.

The worker should ask the insurance company for a link to their MPN so the worker can choose a doctor that will not sell him/her down the river to get more referrals from the insurance company.  If you have an attorney, your attorney can tell you who the “honest” doctors are in the MPN.  If you don’t have an attorney, please feel free to e-mail me the link, and I can tell you which doctors are legit.

The worker has the right to a second and third opinion within the MPN when it comes to diagnosis and/or treatment.  So, if the first MPN doctor does not get it back, the worker can tell the carrier he/she wants a second opinion.

In summation, workers’ compensation medical care has become a very frustrating process where many of the necessary care is being denied to save the insurance company profits.  It is very important that the worker help his/her doctor in justifying the care which is working by bringing in the list of functional improvements in the MPN.

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