Workers' Compensation in California:Questions & Answers

prepared for theCalifornia Commission on Health and Safety and Workers' Compensation

October 2006

Page 2

Page 3

Introduction. How To Use This Booklet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chapter 1. Available Medical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Chapter 2. How Your Treating Physician Is Chosen . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter 3. If You Have a Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Appendix. Important Laws and Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Note: This booklet describes rights and procedures under California law as of October 2006.Many of the new laws governing workers' compensation medical care are still being interpreted,and further changes are expected. To learn about updates, visit the website of the state Divisionof Workers' Compensation: www.dir.ca.gov/dwc.

Page 4

Page 5

Getting appropriate medical care for a work-related injury or illness has become increasinglycomplicated. This booklet is written for injured workers in California who want to learn abouttheir rights, steps to take, and where to go for help. It describes California workers'compensation rules and procedures as of October 2006.

Some workers are covered by a union contract or a labor-management carve-out agreementthat governs injured workers' rights to medical treatment and the steps to take to getappropriate care. If you have a union, find out whether the union contract or a carve-outagreement applies to your situation.

Chapter 1, Available Medical Services, describes your right to receive treatment soon afterinjury, how medical bills are paid, treatment guidelines that affect your medical services, andlimits on chiropractic and other types of care.

Chapter 2, How Your Treating Physician Is Chosen, describes who can treat you right afterinjury and later. The treating physician is responsible for prescribing and coordinatingtreatment for your injury and writing medical reports that affect your other workers'compensation benefits.

Chapter 3, If You Have a Problem, recommends what to do if you encounter a problemgetting appropriate care, and where to go for help to resolve a problem.

The Appendix lists Important Laws and Regulations that govern workers' compensationmedical care. It also explains how to access the laws and regulations.

The term "claims administrator," used throughout the booklet, refers to the person whohandles workers' compensation claims for your employer. Most claims administrators workfor insurance companies or other organizations that handle claims for employers. Some claimsadministrators work directly for large employers that handle their own claims. This personmay also be called a claims examiner or a claims adjuster.

A short introductory factsheet, The Basics About Medical Care for Injured Workers,October 2006, is also available. If you would like to learn about other services and benefits forinjured workers, see Workers' Compensation in California: A Guidebook for InjuredWorkers, Third Edition, 2006. You can download the factsheet and the guidebook from oneof the following websites: www.dir.ca.gov/chswc or www.lohp.org. Many public librariesprovide access to the Web.

Page 6

Page 7

When do my medical services start? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Who pays for my medical services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

What kinds of medical services are available to injured workers? . . . . . . . . . . . . . . . . . . . . 8Medical treatment guidelines used in California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8If your doctor recommends treatment that is not in the guidelines . . . . . . . . . . . . . . . . . . . . . 8If your case is settled with an agreement on future medical care . . . . . . . . . . . . . . . . . . . . . . 8Limits on chiropractic and other types of treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

When do my medical services start?

Always report a work-related injury or illness to your employer as soon as possible. If it's anemergency, your employer must make sure that you have access to emergency medicalservices right away. For non-emergency care, the claims administrator is required to authorizemedical treatment within one working day after you return a workers' compensation claimform to your employer. (Your employer must give or mail you this form, called DWC 1,within one working day after learning about your injury or illness.) While your claim is beinginvestigated, the claims administrator must authorize necessary treatment up to $10,000.

These requirements are found in California Labor Code sections 5401(a) and 5402(c). See theAppendix for instructions on how to access the Labor Code.

Who pays for my medical services?

Your employer pays for medical services for your work-related injury or illness, eitherthrough a workers' compensation insurance policy or by being self-insured. The claimsadministrator pays the medical bills. You should never receive a medical bill, as long as youreturned a claim form to your employer and your physician knows that the injury is work-related.

It is illegal for a physician or medical facility to bill a worker if they know the injury is or maybe work-related. This law is found in California Labor Code section 3751(b).

Page 8

What kinds of medical services are available to injured workers?

California workers' compensation law requires claims administrators to authorize and pay formedical care that is "reasonably required to cure or relieve" the effects of the injury. Underlaws enacted in 2003 and 2004, this means care that follows scientifically based medicaltreatment guidelines.

Medical treatment guidelines used in California

The medical treatment guidelines currently being used in California are the OccupationalMedicine Practice Guidelines, Second Edition, published by the American College ofOccupational and Environmental Medicine (ACOEM).

The ACOEM guidelines are designed to help physicians give appropriate treatment.Research shows that unnecessary care can foster dependence on the medical system andlead to permanent disability. Appropriate care under the ACOEM guidelines includesgiving advice and guidance to the injured worker on how to remain active whilerecovering, and informing the employer what can or should be done to allow this tohappen. Changes at work could involve different job assignments, reduced working hours,or other accommodations that are safe and appropriate for the particular injury. Remainingactive increases the chances that a worker will recover fully and return to full andsustained employment.

If your doctor recommends treatment that is not in the guidelines

Some injured workers have medical conditions requiring treatment that is not in theACOEM guidelines. If your doctor recommends treatment not in the ACOEM guidelines,the claims administrator is required to pay for the treatment if it follows other scientificallybased guidelines that are generally recognized by the national medical community. (Sometreatment guidelines, for example, are available online at the website of the NationalGuideline Clearinghouse: www.guideline.gov.)

For medical conditions not covered by the ACOEM guidelines or other medical treatmentguidelines, the state Division of Workers' Compensation (DWC) proposed a set of rules inJuly 2006 for determining appropriate care. The rules were part of a proposed "MedicalTreatment Utilization Schedule" being considered for adoption at the time this bookletwas written (October 2006).

If your case is settled with an agreement on future medical care

If your workers' compensation case has been settled with an agreement that you willcontinue to receive medical care for your injury, the medical treatment guidelines and rulesdescribed above still apply to you. The guidelines and rules apply to all treatment, even incases that settled before the guidelines were added to workers' compensation law.

Page 9

Limits on chiropractic and other types of treatment

If your date of injury is in 2004 or later, you are limited to a total of 24 chiropractic visits,24 physical therapy visits, and 24 occupational therapy visits for your injury, unless theclaims administrator authorizes additional visits in writing. Also, regardless of your date ofinjury, you may be subject to other limits on these visits based on the medical treatmentguidelines described above.

Page 10

Page 11

What is the role of my treating physician? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Who can treat me right after I am injured? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11If there is a medical provider network (MPN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11If there is a contract with a health care organization (HCO) . . . . . . . . . . . . . . . . . . . . . . . . 12If there is no MPN or HCO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12If you previously predesignated your personal physician . . . . . . . . . . . . . . . . . . . . . . . . . . 12Other situations where you can choose who treats you right after injury . . . . . . . . . . . . . . . 14

Can I switch to a different doctor for treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Choices if you are being treated in an MPN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Choices if you are being treated in an HCO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Choices if you are not being treated in an MPN or HCO . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Choices if you predesignated your personal physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

What is the role of my treating physician?

Your treating physician:- Decides what type of medical care to prescribe for your job injury or illness- Helps determine when you can return to work- Helps identify the kinds of work you can do safely while recovering- Refers you to specialists if necessary- Writes medical reports that may affect the benefits you receive.

Who can treat me right after I am injured?

It depends on whether your employer or the insurer has created a medical provider network(MPN) or has a contract with a health care organization (HCO) to treat injured workers, andwhether you predesignated your personal physician.

If there is a medical provider network (MPN)

An MPN is a list of physicians and other health care providers selected by the employer orinsurer to treat injured workers. MPNs must be approved by the state Division of

Page 12

Workers' Compensation (DWC). An employer or insurer that creates an MPN must givewritten information about the MPN to every employee either 30 days before the MPN isimplemented, when the employee is hired, or when the employee transfers into the MPN.This information must be provided again when a worker gets hurt on the job.

If your employer or the insurer has created an MPN, in most cases you will first be treatedin the MPN after you are injured.

If there is a contract with a health care organization (HCO)

An HCO is an organization certified by the DWC that contracts with an employer orinsurer to provide managed medical care. Most employers and insurers do not havecontracts with HCOs. An employer or insurer that has a contract with an HCO must giveemployees a form prepared by the state Division of Workers' Compensation, DWC Form1194, to allow them to choose whether to enroll in the HCO. This form must be given tonew employees within 30 days after date of hire and to current employees at least once ayear. The form is in the California Code of Regulations, title 8, section 9779.4, and can bedownloaded. (For instructions on how to access the regulations, see the Appendix.)

If your employer or the insurer has a contract with an HCO, in most cases you will first betreated in the HCO after you are injured.

If there is no MPN or HCO

If your employer or the insurer has not created an MPN and does not have a contract withan HCO, in most cases the claims administrator can choose the doctor who first treats youafter you are injured.

If you previously predesignated your personal physician

Some workers are allowed to predesignate their personal physician before injury. Thismeans that before you are injured, you give your employer the name and address of yourpersonal physician in writing. If you predesignate, you may see your personal physicianright after you are injured. You are not required to receive your treatment in an MPN orHCO or from a doctor chosen by the claims administrator.

You can predesignate only if your employer offers a group health plan or group healthinsurance for medical conditions that are unrelated to work. If your employer does notoffer this benefit, you do not have a right to predesignate.

Note: The rights to predesignate and be treated by a predesignated personal physician willend on December 31, 2009, unless this date is extended by law.

Page 13

HOW TO PREDESIGNATE

To predesignate your personal physician (if you are eligible to do so), you must notifyyour employer in writing. You may prepare your own written statement, use optionalDWC Form 9783 provided by the state Division of Workers' Compensation, or use aform provided by your employer. To download DWC Form 9783, go to:www.dir.ca.gov/dwc (link to: Forms). Note: If your employer or the insurer has acontract with an HCO, you must use a different form, discussed below.

Make sure to include the following information:1. Name of your employer2. A statement that if you are hurt on the job, you designate your personal physician

to provide medical care. Give the name, address, and phone number.3. Your name4. Your signature5. Date

You can predesignate a doctor of medicine (M.D.) or doctor of osteopathy (D.O.)who treated you in the past and has your medical records. The doctor must be ageneral practitioner, internist, pediatrician, obstetrician-gynecologist, or familypractitioner who is your primary care physician. You cannot predesignate yourpersonal chiropractor or acupuncturist.

The doctor must agree in advance to treat you for any job injuries and illnesses. Theagreement must be documented, either by the doctor signing the predesignation formor by some other form of documentation. Include the documentation when you giveyour employer the predesignation form or statement.

Starting on January 1, 2007, you will be allowed to predesignate your personalphysician's medical group. "Personal physician" will be defined in California LaborCode section 4600 as including a medical group that provides comprehensive medicalservices mostly for medical conditions unrelated to work. To predesignate yourpersonal physician's medical group, ask your physician for its exact name and put it onyour predesignation form or statement.

HCOs. If your employer or the insurer has a contract with an HCO, you will be givenDWC Form 1194 within 30 days after your date of hire and at least once a year. Youcan use this form to predesignate your personal physician, personal chiropractor, orpersonal acupuncturist. You are not required to show that your doctor agreed to bepredesignated. If you do not predesignate each time you are given this form, youremployer will enroll you in the HCO for job-related injuries.

Page 14

Other situations where you can choose who treats you right after injury

Sometimes an injured worker has a right to choose the treating physician even if he or shedid not predesignate:

C If your employer did not post required information about your workers' compensationrights, including the right to predesignate your personal physician, you can go to yourpersonal physician right after you are injured.

C If your employer or the insurer sends you to treatment that is completely inadequate orrefuses to provide necessary care, you can go to a physician of your choice.

If you believe one of these situations applies and you would like to be treated by yourpersonal physician or another physician of your choice, get help immediately to avoid apossible dispute about who can choose the physician. Use the resources described on page23.

Can I switch to a different doctor for treatment?

Yes. The doctors you may switch to depend on whether you are being treated in a medicalprovider network (MPN) or a health care organization (HCO) and whether you predesignatedyour personal physician.

Choices if you are being treated in an MPN

If you are being treated in an MPN, after the first medical examination of your injury, youare allowed to switch to another doctor within the MPN, and you may switch againwhenever it is reasonable to do so. Your employer or the insurer must give you writteninformation on how to do this. In most cases, you are not allowed to switch to a doctoroutside the MPN.

Choices if you are being treated in an HCO

If you are being treated in an HCO, you are allowed to switch at least one time to anotherdoctor within the HCO. The HCO must give you a choice of physicians within 5 days afteryou request a change. Also, if you gave your employer the name of your personalchiropractor or acupuncturist in writing before you were injured, you may switch to yourchiropractor or acupuncturist upon request, after you first see a doctor chosen by theclaims administrator.

If you are receiving or are eligible to receive employer-provided health insurance formedical conditions unrelated to work, then 180 days after you report your injury or illnessto your employer (or 180 days after your employer learns about it), you are allowed to

Page 15

switch to a doctor of your choice outside the HCO. If you are not receiving or are noteligible to receive employer-provided health insurance for medical conditions unrelated towork, then 90 days after you report your injury or illness to your employer (or 90 daysafter your employer learns about it), you are allowed to switch to a doctor of your choiceoutside the HCO.

When you switch to a doctor outside the HCO, the new doctor can be a medical doctor,osteopath, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractor.You or the new doctor must give the claims administrator the doctor’s name and address.This allows the claims administrator to obtain medical reports and pay for your medicalcare. You may switch again whenever it is reasonable to do so.

Choices if you are not being treated in an MPN or HCO

If you are not being treated in an MPN or HCO, you have a right to switch to a newdoctor one time during the first 30 days after you report your injury or illness to youremployer (or 30 days after your employer learns about it), but usually the claimsadministrator is allowed to choose the new doctor. However, if you gave your employerthe name of your personal chiropractor or acupuncturist in writing before you wereinjured, you may switch to your chiropractor or acupuncturist upon request, after you firstsee a doctor chosen by the claims administrator.

After 30 days, you are allowed to switch to a doctor of your choice if you still needmedical care and your employer or the insurer still has not created an MPN. The newdoctor can be a medical doctor, osteopath, psychologist, acupuncturist, optometrist,dentist, podiatrist, or chiropractor. You or the new doctor must give the claimsadministrator the doctor’s name and address. This allows the claims administrator toobtain medical reports and pay for your medical care. You may switch again whenever itis reasonable to do so.

Choices if you predesignated your personal physician

If you predesignated your personal physician and your employer or the insurer has createdan MPN, you may switch to a new doctor within the MPN, and you may switch againwithin the MPN whenever it is reasonable to do so. Your employer or the insurer mustgive you written information about how to select a doctor within the MPN. However,your predesignated personal physician may refer you to another doctor outside the MPNfor consultation or specialized treatment.

If you predesignated your personal physician and your employer or the insurer has acontract with an HCO, you may switch to a new doctor within the HCO. Also, if you gaveyour employer the name of your personal chiropractor or acupuncturist in writing beforeyou were injured, you may switch to your chiropractor or acupuncturist upon request.

Page 16

You may switch again as described above, under "Choices if you are being treated in anHCO."

If you predesignated your personal physician and your employer or the insurer has notcreated an MPN and does not have a contract with an HCO, you may switch to a newdoctor, but usually the claims administrator is allowed to choose the new doctor.However, if you gave your employer the name of your personal chiropractor oracupuncturist in writing before you were injured, you may switch to your chiropractor oracupuncturist upon request. You may switch again as described above, under "Choices ifyou are not being treated in an MPN or HCO."

Page 17

How can I avoid problems in getting appropriate treatment? . . . . . . . . . . . . . . . . . . . . . . . 17

I don't agree with my treating physician about necessary treatment. What . . . . . . . . . . . 18can I do?

Steps to take if you are being treated in an MPN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Steps to take if you are being treated in an HCO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Steps to take if your are not being treated in an MPN or HCO . . . . . . . . . . . . . . . . . . . . . . 19

I agree with my treating physician about necessary treatment. How long can . . . . . . . . . 20the claims administrator take to decide whether to authorize treatment?

Decisions based on utilization review (UR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Second opinions on spinal surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21What you can do to speed up the decision-making process . . . . . . . . . . . . . . . . . . . . . . . . 21Situations where treatment recommended by your doctor can be denied . . . . . . . . . . . . . . 22

I don't agree with a decision to deny treatment. What can I do? . . . . . . . . . . . . . . . . . . . . 22Steps to challenge most decisions to deny treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Steps to challenge a decision to deny spinal surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Penalties for treatment being delayed or denied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22How to file a complaint about treatment being delayed or denied . . . . . . . . . . . . . . . . . . . . 23

Where can I go for help with problems in getting the right medical services? . . . . . . . . . 23

How can I avoid problems in getting appropriate treatment?

Understand your physician's treatment plan, and request copies of all medical reports aboutyour injury. These reports, which your doctor is required to send to the claims administrator,describe the nature of your injury, causes of the injury, necessary treatment, and types of workyou can do while recovering. The doctor and claims administrator are required to give youcopies if you request them (except in some cases when the request is for mental healthrecords). If you have questions about a particular report, ask the doctor.

Page 18

I don't agree with my treating physician about necessary treatment. Whatcan I do?

If you don't agree with your treating physician about necessary treatment, you have a right toget another doctor's opinion. The steps to take to get another opinion depend on whether youare receiving care within a medical provider network (MPN), a health care organization(HCO), or neither.

Note: You use the steps described below only to challenge an opinion about the kinds ofmedical tests or treatment you need. If you want to challenge another type of opinion in amedical report, such as an opinion about the causes of your injury or the kinds of work youcan do, there are different steps to take. To learn about these steps, see Workers'Compensation in California: A Guidebook for Injured Workers, Third Edition, 2006,available online: www.dir.ca.gov/chswc or www.lohp.org.

Steps to take if I you are being treated in an MPN

If you are receiving care within an MPN and wish to challenge the treatment prescribed bythe doctor who is treating you, first consider switching to another doctor within the MPN.Your employer or the insurer must give you written information on how to changedoctors within the MPN. See if you can reach agreement with the new doctor.

If you cannot reach agreement with the new doctor, you can obtain opinions from up totwo more doctors within the MPN. These are called second and third opinions. Youremployer or the insurer must give you written information on how to do this. You mustmake appointments to see these doctors within 60 days after you receive a list of availabledoctors from the claims administrator. If you don't make the appointments within 60 days,you risk losing the right to get the other doctors' opinions.

If you do not agree with the second and third doctors, you can obtain an independentmedical review arranged by the state Division of Workers' Compensation (DWC). If thatdoctor agrees with you about necessary treatment, you may obtain the treatment from aphysician outside the MPN.

Steps to take if you are being treated in an HCO

If you are receiving care within an HCO and wish to challenge the treatment prescribed bythe doctor who is treating you, first consider switching to another doctor within the HCO.The HCO must give you a choice of physicians within 5 days after you request a change.See if you can reach agreement with the new doctor.

If you cannot reach agreement with the new doctor, you can obtain an opinion fromanother doctor within the HCO. If you do not agree with this doctor, you can ask the

Page 19

HCO to resolve the dispute through an expedited grievance procedure. The HCO mustissue a written decision within 30 days, or sooner if your condition requires a fasterdecision.

Steps to take if you are not being treated in an MPN or HCO

If you are not receiving care within an MPN or HCO and wish to challenge the treatmentprescribed by the doctor who is treating you, first consider switching to another doctor.Chapter 2 explains your choices in switching doctors.

If you cannot switch or cannot reach agreement with the new doctor, you can take thesteps below.

1. Send a letter to the claims administrator stating that you disagree with themedical report:

C If you do not have an attorney, you must send the letter within 30 days after youreceived the report.

C If you have an attorney, your attorney must send the letter within 20 days afterreceiving the report.

If the letter is not sent before the applicable deadline, you risk losing the right tochallenge the treating doctor's opinion.

2. Get a medical opinion, or evaluation, from another doctor:

C If you do not have an attorney:

– The claims administrator must send you instructions on how to contact thestate Division of Workers' Compensation (DWC) to select a qualified medicalevaluator (QME). QMEs are doctors who are certified by the DWC to conductmedical evaluations in workers’ compensation cases.

– Within 10 days after the claims administrator sends you the instructions, youmust select the medical specialty of the QME and contact the DWC for a panel(list) of three QMEs. Within 10 days after the DWC sends you a panel, youmust choose a QME from the panel, make an appointment to be examined bythe QME, and tell the employer of your choice and appointment time. If youdo not act within these deadlines, the claims administrator will choose thedoctor you must see.

Page 20

C If you have an attorney:

– Your attorney and the claims administrator may agree on a doctor called anagreed medical evaluator (AME). AMEs are not required to be certified by theDWC.

– If you were injured in 2005 or later and agreement cannot be reached, yourattorney or the claims administrator may contact the DWC for a panel (list) ofthree QMEs. Your attorney and the claims administrator may agree onsomeone from this panel. If agreement still cannot be reached, your attorneyand the claims administrator may each strike one name from the panel, and theremaining QME will conduct the evaluation.

– If you were injured before 2005 and agreement cannot be reached, yourattorney will select a QME.

In either case, the QME or AME will examine you and write a medical-legal reportdescribing your condition.

Important! You or your attorney should select the appropriate medical specialty andchoose the QME or AME carefully. The medical-legal report will affect your benefits.In many cases, you will not be able to choose another QME or AME. For help, use theresources described on page 23.

For more information about medical evaluations, call the DWC's Medical Unit at 1-800-794-6900. Ask for their written guide, Your Medical Evaluation. Also visit the MedicalUnit website: www.dir.ca.gov/imc.

I agree with my treating physician about necessary treatment. How long canthe claims administrator take to decide whether to authorize treatment?

This depends on whether your medical condition is considered urgent. Claims administratorsmust decide whether to authorize and pay for treatment within time frames that are part of theutilization review (UR) process described below. If your treating physician recommends spinalsurgery, the claims administrator may also obtain a second opinion, described on the nextpage.

Decisions based on utilization review (UR)

In the utilization review process, the claims administrator may decide to approvetreatment, but he or she is not permitted to modify, delay, or deny treatment. Only a

Page 21

physician who is qualified to evaluate the recommended treatment may do this. If thishappens, the claims administrator will communicate the decision to you and your treatingphysician.

C If your medical situation is considered urgent: This means you face a serious threatto your health, or a longer time frame could harm your ability to recover fully. If this isthe case, the decision to approve, modify, delay, or deny the medical treatmentrecommended by your treating physician must be made within 72 hours after theclaims administrator receives the information needed to make the decision, or sooner ifyour condition requires a faster decision. The claims administrator must communicatethe decision to the physician by phone or fax, and to the physician and worker inwriting, within 24 hours of the decision.

C If your medical situation is not considered urgent: The decision to approve,modify, delay, or deny the treatment recommended by your treating physician must bemade within 5 working days after the claims administrator receives the physician'srequest for authorization along with the information needed to make the decision. Ifthe claims administrator needs more time to obtain necessary information, the decisioncan be made up to 14 days after receiving the physician's request. The claimsadministrator must communicate the decision to the physician by phone or fax, and tothe physician and worker in writing, within 24 hours of the decision.

Second opinions on spinal surgery

If the treating physician recommends spinal surgery, the claims administrator may alsoobtain a second opinion from an orthopedic surgeon or neurosurgeon. If you arerepresented by an attorney, the claims administrator must first seek your attorney'sagreement on the doctor who will give the second opinion. If agreement cannot bereached or if you are not represented by an attorney, the claims administrator may ask theDWC to randomly select the doctor who will give the second opinion.

What you can do to speed up the decision-making process

The claims administrator must authorize treatment that follows the ACOEM guidelines orother scientifically based medical treatment guidelines (see Chapter 1). If treatment doesnot follows these kinds of guidelines, the treating physician must show why the treatmentis needed.

Sometimes treatment is delayed because the claims administrator has not received all ofthe information needed from the treating physician. To help avoid delay, encourage yourtreating physician to respond promptly to questions and requests from the claimsadministrator about your medical condition and why you need the recommendedtreatment. Also encourage the doctor to identify, if possible, any scientifically basedmedical treatment guidelines that support the recommended treatment.

Page 22

Situations where treatment recommended by your doctor can be denied

Treatment can be denied if there is no scientific basis for the treatment. The claimsadministrator must clearly explain the reasons for denying treatment.

I don't agree with a decision to deny treatment. What can I do?

To challenge a decision to deny treatment recommended by your treating physician, you cantake the steps below. Note: You must take special steps if the decision was to deny spinalsurgery.

Steps to challenge most decisions to deny treatment

1. Send a letter to the claims administrator stating that you disagree with the decision.You must do this within 20 days after you received the decision from the claimsadministrator, regardless of whether you have an attorney. If you don't send the letterwithin 20 days, you risk losing the right to challenge the decision.

2. Get a medical opinion, or evaluation, from a qualified medical evaluator (QME) oragreed medical evaluator (AME). The procedures are the same ones taken by workerswho are not being treated in an MPN or HCO who wish to challenge treatingphysicians' opinions about necessary treatment. To challenge a decision to denytreatment, the procedures are the same regardless of where you are being treated. Tolearn about these steps, see pages 19-20.

3. Request an expedited hearing before a workers' compensation judge. For help inrequesting a hearing, use the resources described in the next question.

Steps to challenge a denial of spinal surgery

If you disagree with a decision to deny spinal surgery recommended by your treatingphysician, then within 10 days after receiving the decision you must inform the DWC thatyou disagree and that you request a second opinion. If you don't do this within 10 days,you risk losing the right to challenge the decision. (These requirements are based on arecent legal interpretation and may change.) For help in contacting the DWC, use theresources described in the next question.

Penalties for treatment being delayed or denied

If the claims administrator delays or denies treatment without any reasonable excuse, youcould be awarded a penalty payment of up to 25% of the value of each service that wasunreasonably delayed or denied, up to $10,000. For help in requesting penalty payments,

Page 23

contact a state Information & Assistance (I&A) officer or an attorney. To learn aboutI&A officers and attorneys, see the next question.

How to file a complaint about treatment being delayed or denied

The Audit Unit of the state Division of Workers' Compensation (DWC) investigatescomplaints and imposes penalties if a claims administrator misses utilization review (UR)deadlines in deciding whether to authorize and pay for treatment. The Audit Unit alsoimposes large monetary penalties when a claims administrator unreasonably delays ordenies medical care and other benefits "with a frequency that indicates a general businesspractice." Audit penalties are paid to the state, not to the injured worker. For instructionson how to file a complaint with the Audit Unit, contact an I&A officer (see the nextquestion).

Where can I go for help with problems in getting the right medical services?

If you encounter a problem in getting the right medical services, see whether your employer orthe claims administrator can agree to resolve the problem. If this doesn’t work, don’t delaygetting help. Try the following:

C Contact an Information & Assistance officer. State I&A officers answer questions andhelp injured workers. They may provide information and forms and help resolve problems.Some I&A officers hold workshops for injured workers. To contact a local office, checkthe Government Pages at the front of the white pages of your phone book. Look under:State Government Offices/Industrial Relations/Workers’ Compensation. Or call toll-free:1-800-736-7401. You can visit their website at www.dir.ca.gov/dwc (link to: DWCprograms and units/ Information and Assistance).

C Consult an attorney. Lawyers who represent injured workers in their workers’compensation cases are called applicants’ attorneys. Their job is to protect your rights,plan a strategy for your case, gather information to support your claim, keep track ofdeadlines, and represent you in hearings before a workers’ compensation judge. (Workers'compensation judges hear cases and decide on problems and disputes.) You can get namesof applicants’ attorneys from the State Bar of California (1-415-538-2120;www.calbar.ca.gov), a local bar association, or the California Applicants’ AttorneysAssociation (1-800-459-1400; www.caaa.org).

C Contact your union. Your union may be able to help resolve problems, tell you aboutother available benefits, negotiate changes needed in your job, protect you from jobdiscrimination, and refer you to legal services.

Page 24

C Represent yourself. If you can’t get help from the above resources, you can prepare yourown case and request a hearing before a workers’ compensation judge to resolve aproblem or dispute. For instructions, contact an Information & Assistance officer (seeabove).

Page 25

Laws and regulations that govern workers' compensation medical care are listed below.Except where noted otherwise, you can download these laws and regulations from the websiteof the state Division of Workers' Compensation (DWC): www.dir.ca.gov/dwc (link to"Statutes" and "Regulations").

Chapter 1

- Employer must ensure access to emergency medical services: California Code ofRegulations, title 8, section 3400 (available online at www.dir.ca.gov/dosh; link to: Title 8regulations)

- Right to medical care within one working day after filing claim form: California LaborCode section 5402(c)

- Employer must give or mail claim form within one working day after learning about injury:California Labor Code section 5401(a)

- Employer must pay for workers' compensation and must have insurance or be self-insured:California Labor Code sections 3600 and 3700

- Illegal for medical provider to bill injured worker while claim is pending: California LaborCode section 3751(b)

- Right to medical care based on treatment guidelines: California Labor Code sections 4600,4604.5, and 5307.27

- Limits on chiropractic, physical therapy, and occupational therapy visits: California LaborCode sections 4604.5(d)

Chapter 2

- Medical provider networks (MPNs): California Labor Code sections 4616-4616.7;California Code of Regulations, title 8, sections 9767.1-9767.15

- Health care organizations (HCOs): California Labor Code section 4600.3-4600.7;California Code of Regulations, title 8, sections 9770-9779.9

Page 26

- Predesignating your personal physician: California Labor Code section 4600(d); CaliforniaCode of Regulations, title 8, sections 9780-9783.1

- Predesignating your personal physician if employer or insurer has a contract with an HCO:California Labor Code section 4600.3(a); California Code of Regulations, title 8, sections9779.3-9779.4

- Right to be treated by your personal physician if employer did not post information aboutyour workers' compensation rights: California Labor Code sections 3550(e) and 3551

- Switching to a different doctor if you are being treated in an MPN: California Labor Codesections 4600(c) and 4616.3(b) and (d); California Code of Regulations, title 8, section9767.6(d), (e), and (f)

- Switching to a different doctor if you are being treated in an HCO: California Labor Codesections 3209.3 and 4600.3(c), (e), and (g); California Code of Regulations, title 8,section 9773(b)(6)

- Switching to your personal chiropractor or acupuncturist: California Labor Code section4601(b) and (c); California Code of Regulations, title 8, sections 9781(b) and 9783.1

- Switching to a different doctor if you are not being treated in an MPN or HCO and youdid not predesignate: California Labor Code sections 3209.3, 4600(c), and 4601(a);California Code of Regulations, title 8, section 9781

- Switching to a different doctor if you predesignated: California Labor Code sections3209.3, 4600(c), 4600.3(a), (c), (e), and (g), and 4616.3(b); California Code ofRegulations, title 8, sections 9767.6(d), (e), and (f), 9773(b)(6), 9780.1(d), 9781, and9783.1

Chapter 3

- Treating physician's reports: California Code of Regulations, title 8, sections 9785-9785.4

- Claims administrator must provide copies of medical reports upon request: CaliforniaCode of Regulations, title 8, section 9810(d)

- Physician must provide copies of medical reports upon request: California Health andSafety Code sections 123100-123149.5 (available online at www.leginfo.ca.gov; link to:California Law)

Page 27

- Challenging diagnosis or treatment decisions in an MPN: California Labor Code sections4616.3(c), 4616.4, and 4616.6; California Code of Regulations, title 8, sections 9767.7and 9768.1-9768.17

- Challenging diagnosis or treatment decisions in an HCO: California Labor Code sections4600.3(e) and 4600.5(d)(6); California Code of Regulations, title 8, sections 9773(b)(7)and 9775

- Challenging diagnosis or treatment decisions if not in an MPN or HCO: California LaborCode sections 4062-4068

- Utilization review (UR): California Labor Code section 4610; California Code ofRegulations, title 8, sections 9792.6-9792.10

- Spinal surgery second opinion procedure: California Labor Code section 4062(b) and (c);California Code of Regulations, title 8, sections 9788.01-9788.91

- Challenging a decision to deny treatment: California Labor Code section 4062(a);California Code of Regulations, title 8, section 9792.10

- Penalties for unreasonable delay or denial: California Labor Code sections 5814 and5814.5

- Complaints and Audit Unit investigations where there is a failure to meet UR deadlines:California Labor Code section 4610(i)

- Complaints and Audit Unit investigations of unreasonable delays and denials: CaliforniaLabor Code section 5814.6

This booklet was prepared by the Institute of Industrial Relations (IIR), University of California atBerkeley, and the Labor Occupational Health Program (LOHP), Center for Occupational andEnvironmental Health, School of Public Health, University of California at Berkeley, incollaboration with the California Department of Industrial Relations, the Commission on Healthand Safety and Workers' Compensation (CHSWC), and the Division of Workers' Compensation(DWC).

Copyright © 2006, IIR, LOHP, and CHSWC. All or portions of this booklet may be reproducedwithout permission for educational purposes. Please credit IIR, LOHP, and CHSWC.