A common question we get asked by injured workers is what kind of medical treatment they can expect under the Workers' Compensation insurance system. In short, often very little.
While there are certainly cases where insurance administrators have accepted claims and authorized decades' worth of medical treatment, including extensive surgeries, recent reforms have enabled insurance companies to drastically limit their obligation for authorizing and paying for treatment. It can get frustrating when your treating doctor prescribes certain medications, physical therapy, a surgical consult, or even surgery, and all you hear back from the claims administrator is that they're going to deny what seems to you like necessary medical treatment.
In this article, we'd like to address why this happens. Workers' Compensation is a system of very limited benefits, and we stress that to every client who walks in our door. We find that if clients have reasonable expectations (i.e. lower expectations) about what benefits they can obtain within the system, the less stress they'll have to endure as their claims are pending. Part of having reasonable expectations is understanding what type of medical treatment to expect to get under this system.
Emergency Medical Care
If you've been injured at work and it requires emergency medical treatment, call 911, ride the ambulance, go to the Emergency Room, and otherwise do whatever it is you need to do to treat that emergency as soon as possible. Workers' Compensation will cover up to $10,000 in medical expenses up until the time the claims administrator decides to accept or deny your claim. The timeframe for accepting or denying your claim is 90 days.
If you do not have private health insurance, the hospital may end up billing you directly for medical treatment. At this point, you can talk to the hospital billing department and let them know you were in the hospital for a Work Comp injury and that the hospital needs to bill the Workers' Compensation insurance carrier instead. We've seen cases, however, where the claims administrator has denied a claim and fails to make that obligatory payment for emergency medical care. You may have some remedies for this situation, but the hospital or medical treatment provider can send you to collections, which will ding your credit score in the mean time.
Authorizing Treatment Under the Medical Utilization Review Process
Even if the claims administrator has accepted your claim, authorizing necessary medical treatment can take years. Your treating doctor must generally be part of the Workers' Compensation system's Medical Provider Network. These doctors are licensed physicians that insurance companies or self-insured businesses (e.g., Walmart) designated to be part of the Network. California maintains regulations as to who can be part of that Network, and each Network must contain doctors with a different variety of specialties.
So, imagine you're already seeing a doctor designated by the insurance company and have no choice to choose to see your regular doctor. Your treating doctor wants to send you to a specialist for a surgical consultation, and would like to also prescribe some physical therapy and pain medication. A different doctor who you will never meet can review that treating doctor's request and deny it.
How does this happen?
In addition to your treating doctor, a doctor who is part of what's called a Utilization Review (UR) process must review every request for authorization of medical treatment. The UR doctor reviews the request without ever meeting you, the patient. In the UR doctor's review, they may decide to accept, deny, delay, or modify the requested treatment. The insurers have direct oversight over the UR program, and it's very possible that UR doctors will feel inclined to deny treatment requests in the face of very clear medical evidence that someone needs to see a specialist, get an MRI, get an x-ray, or any number of treatments.
Independent Medical Review
While the UR process may seem inherently unfair, the state implemented a process where injured workers can appeal the decisions of the UR doctors. This process is called Independent Medical Review (IMR).
Maximus is the sole entity responsible for administering the IMR, and contracts with physicians around the state to review authorization denials. IMR upholds about 80 to 90% of the denials, depending on the treatment being requested. In the meantime, while waiting for your likely denial, your injuries could be getting worse as it goes untreated.
Solutions for Getting Adequate Medical Treatment
We often advise clients to not freak out if their Workers' Compensation claim gets denied. Upon denial, this means you can treat privately outside of the Workers' Compensation system, and many clients find they would prefer to get treatment from their own trusted doctors as their claims are pending. If you do not currently have private insurance, under the current federal health care system, you can qualify and apply for Medi-Cal at any time.
If you're currently stuck in the system, however, another method is to simply dial up your claims administrator when denials happen. If you speak to them respectfully, you'd might get something authorized. Calling is effective - just remember that claims administrators are people, too.