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Why Can’t I Get Medical Treatment?

Every day our clients ask why their medical treatment is not being authorized.

The short answer is that the law in workers compensation with regard to medical treatment has become very technical, overregulated, and quite frankly complicated.

Every single case must be reviewed in the following manner:

1.    IS THE INJURY DENIED?

If the injury being claimed is denied, workers compensation will not authorize any treatment until this issue is resolved. It is usually resolved after the injured worker has seen a neutral doctor, i.e. an agreed medical doctor or a panel qualified medical doctor.

2.     IS THE BODY PART DENIED?

If workers compensation accepts that the injury caused is to one part of the body, but denies responsibility for another part of the body, they will not authorize any treatment for the denied body part until this issue is resolved. These resolutions are the same as number one above.

3.    IS YOUR TREATING DOCTOR AUTHORIZED AS A PRIMARY TREATING PHYSICIAN, OR AN   AUTHORIZED  CONSULTANT OF THE PRIMARY  TREATING PHYSICIAN

In a larger number of cases, when both the injury and the body part in question are accepted, the treatment still has to be by an authorized physician in a Medical Provider Network. Each workers compensation insurance carrier and or self-insured employer has the right to contract with a specific Medical Provider Network. The injured worker must carefully select from the proper network.

4.     REQUEST FOR AUTHORIZATION FORM.

Each primary treating physician must make all request for medical treatment and prescriptions using a specific form created by the Workers Compensation Appeals board titled “Request For Authorization Form”. Failure to submit this form will probably result in no authorization of treatment. When this form is properly submitted, the date it is submitted is critically important because it begins the time periods listed below.

5.      UTILIZATION REVIEW

If the workers compensation carrier does not authorize the treatment requested in the “Request For Authorization Form”, they have five business days to issue a “Utilization Review Determination”. These determinations are issued by separate companies with whom the workers compensation carrier has contracted. If the determination states that the requested treatment is not authorized, it must state the appropriate medical treatment guideline upon which this opinion is based.

6.      INDEPENDENT MEDICAL REVIEW

Within 30 days of the receipt of a Utilization Review Determination denial, the injured worker, on a form prescribed by the state of California, which must be attached to the denial, must request Independent Medical Review.  Independent Medical Review is performed by a company named Maximus with whom the state of California has contracted. When the request for Independent Medical Review is received by the Medical Unit of the State of California, under the current proposed regulations they have 15 days to determine if this case is eligible for Independent Medical Review. If there is eligibility, Maximus has 30 days to issue a written decision as to whether or not the treatment requested should be authorized. If the decision of Independent Medical Review denies the authorization, there are very few grounds for appeal. There is no statutory right to judicial review which means that you cannot go to court and present these issues to a workers’ compensation judge.

CONCLUSION:

Every single request for medical treatment even if it is for aspirin or three physical therapy visits must go through the above process.

At the time of this article, more request for medical treatment than ever before are being denied. It has become a statewide crisis. I’m sure that from what you have read above, you can see why this has occurred.

While we want you to know that we are very carefully monitoring each step of the above procedures in your case, we also want you to know why it takes so long for treatment to be authorized if at all.

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  • Los Angeles Office
    4221 Wilshire Boulevard
    Suite 460
    Los Angeles, California 90010
    Phone: 213-251-5900
    Fax: 213-386-2750
Million Dollar Results
  • "MULTIMILLION DOLLAR AWARD:For injuries sustained to a physician blood pathologist, after being exposed to formaldehyde in the workplace."

  • "MILLION DOLLAR SETTLEMENT: Verizon field technician injured at work incurring serious injuries to the lower back, neck (fusion) and upper/lower extremities."

  • "MILLION DOLLAR SETTLEMENT: Semi-truck driver involved in an out-of-state collision while working for a Hollywood entertainment company - resulting in severe lower back, neck, chest, head, urological and psychiatric disabilities."

  • "MILLION DOLLAR AWARD: A welder received compensation for his injuries as a result of cadmium exposure causing brain damage."

  • "$1.4 MILLION SETTLEMENT: A sheet metal installer was compensated after sustaining injuries to his entire body from falling 14ft off a scissors lift."

  • "MULTIMILLION DOLLAR AWARD: Versus Coca-Cola for an injured worker who fell from a forklift and struck his head sustaining blunt force trauma to his neck, spine and shoulder."

  • "OVER $ 1 MILLION DOLLAR SETTLEMENT: Southern California Edison Employee who sustained Fibromyalgia and Psychiatric consequences of the stress and wear-and-tear of her employment."

  • "MILLION DOLLAR AWARD: Versus Warner Brothers for employee who sustained severe spinal disabilities as a result of the physical wear-and-tear of his employment."