How do I get medical treatment for a work injury in California?
The care is supposed to be paid for. The hard part is the rules about which doctor you can see, and what happens when an insurance reviewer who has never met you says no.
Questions about your case? Call (323) 656-9040.
Your employer pays for the medical care, and nobody should be sending you a bill. As soon as you turn in your claim form, up to $10,000 in treatment has to be authorized while the insurer decides on the claim. If your employer uses a Medical Provider Network, you'll treat with doctors on that list.
"Which doctor am I allowed to see?"
Usually one from your employer's Medical Provider Network, or MPN. That's the insurer's approved list of doctors for work injuries. You don't have to stay with the first one. After the first visit you can switch to another doctor in the network, and you can switch again later when it's reasonable. Going outside the network generally isn't covered unless an exception applies.
There's one way to keep your own doctor from day one, and it only works if you set it up before you got hurt. It's called predesignation. You need non-work health coverage on the date of injury. You need to have told your employer, in writing and before the injury, which doctor you want (DWC Form 9783 works but isn't required). The doctor has to be an M.D. or D.O. in general practice, internal medicine, pediatrics, OB-GYN or family practice who has treated you before and has your records, or a qualifying medical group. And the doctor has to have agreed in advance to treat a work injury.
Not hurt yet, reading this for later? Set it up now. It's the single easiest thing you can do ahead of time.
Sources: DWC Injured Worker Guidebook, Chapter 3; Chapter 1.
"Who pays, and when does it start?"
Your employer, through its insurance. Once you hand in the DWC-1, your employer has one working day to authorize treatment, and the insurer is on the hook for up to $10,000 while it decides whether to accept the claim. If it doesn't deny the claim within 90 days of the form being filed, the injury is presumed covered (Labor Code section 5402).
No claim form yet? Your employer owes it to you within one working day of learning about an injury that needs more than first aid (Labor Code section 5401). Ask in writing.
About copays and bills: an employer can't make you pay any part of the cost of workers' comp, and while the claim is pending, a provider can't bill you for treating the injury until there's a written denial (Labor Code section 3751). Got a bill anyway? Don't pay it yet. Call the insurer, then call us.
Sources: DWC, Information for injured workers; Labor Code § 5401, § 5402, § 3751.
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"They denied the treatment my doctor asked for."
This is where most people get stuck. When your doctor requests an MRI, surgery, therapy or a prescription, the insurer runs it through utilization review, or UR. A reviewing doctor who has never examined you decides whether it's medically necessary.
If UR says no, or approves something less, you can ask for independent medical review, or IMR. An outside doctor looks at the records and makes the call. You have 30 days from when the UR decision was served on you to ask. Miss that window and the denial usually sticks. Put the date on your fridge.
| Step | Deadline |
|---|---|
| Routine UR decision | 5 working days, up to 14 if they need more information |
| Urgent UR decision | 72 hours |
| Your request for IMR | Within 30 days of service of the UR decision |
| IMR decision | Within 30 days (5 working days for formulary drug disputes) |
Sources: DWC Injured Worker Guidebook, Chapter 4; Labor Code § 4610.5, § 4610.6; DWC IMR page.
"I don't agree with what my doctor wrote."
UR and IMR only handle one question: is this treatment needed? Fights about anything else, like whether work caused the injury, whether you can work, or how permanent it is, go a different route, usually through a Qualified Medical Evaluator or an Agreed Medical Evaluator. The QME guide walks through it.
"My claim was denied. Now what about my treatment?"
The no-billing protection lasts only while the claim is pending. Once there's a written denial, providers can bill you. A denial can be fought, though, and the sooner the better. Start with what to do when your claim is denied. And if you just want to ask the state a question, its Information and Assistance officers take calls at 1-800-736-7401. They'll explain the rules, but they can't represent you.
The same rules apply whatever the injury, whether it's a crash on a work route or carpal tunnel from years on the line.
Let's talk about what happened.
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