Medical Treatment - Who Gets To Choose The Treating Doctor

One of the most important changes in Workers Compensation is that the injured worker is no longer allowed to treat with any doctor of their choice. In most cases, the injured worker is required to treat with a doctor who is a member of the employer or insurance company’s medical provider network (MPN). An injured worker can treat with any doctor who is a member of the MPN. This office has an extensive list of participating MPN doctors. I will do my best to direct you to the MPN doctor who will give you the best possible care within the limitations of the MPN.

If your claim is denied, or you were not timely provided with medical treatment after your injury, you are entitled to treat outside the MPN. In certain circumstances, you may be able to treat outside the MPN if your case is admitted.

In all cases, the injured worker is limited to 24 physical therapy, 24 chiropractic, and 24 occupational therapy visits per claim. The days being off work and getting 3 PT visits per week for one and a half years are over. However, if the injury requires surgery, than the insurance company may, but is not required to, authorize additional therapy.

Medical treatment is limited by the American College of Occupational and Environmental Medicine Practice Guidelines (ACOEM). ACOEM assumes that all human beings will respond in the same way to medical treatment. In practice, the ACOEM Guidelines are wrongfully applied by the insurance company to deny care. This causes major delays and denials of care.

When a doctor makes a request for medical treatment, diagnostic test, medical appliance, or other medical procedure, the insurance company may direct these requests to a utilization reviewer. This reviewer will not examine or talk to the injured worker. In many cases, this reviewer will not even talk to the treating doctor. Many times, the reviewer will be an out of state doctor, chiropractor, or osteopath employed by the insurance company. The reviewer will look at notes and reports, and make the treatment decision based on ACOEM. Absent a life threatening situation, the insurance company has 14 days from the receipt of the information to make a utilization review decision.

In summary the 2004 workers’ compensation reform changed medical care in California’s workers’ compensation system from being a system where the injured worker could obtain all the medical treatment he/she wanted form any doctor of their choice to a system of limited doctor choice and limited treatment options. The injured worker should expect treatment not much better than an HMO plan. Out of control medical costs were a major reason for the dramatic workers’ compensation reform.