workerscomp

California’s Department of Industrial Relations, which administers the state’s workers’ compensation system, is fielding criticism from injured workers and doctors who say getting authorization for medical treatment is unreasonably difficult. According to an NBC Bay Area news report, the director of that department, Christine Baker, has defended the system saying that reforms made four years ago improved access to medical treatment and helped contain costs. Many others claim, however, that critical medical care needed to get injured workers back on the job has been delayed or even denied by employers and insurance companies.

Did Recent Workers’ Comp Reforms Work?

The major changes to the workers’ compensation system in California launched in 2013 under Senate Bill 863 placed emphasis on evidence-based medicine and essentially moved treatment decisions from courts to medical reviewers while using state-approved guidelines to authorize or deny treatment requests. Advocates of this reform said that under such a system, benefits would go to the workers who will get quicker and more appropriate treatment.

However, according to recent reports, the reforms also cut costs by more than $1 billion per year. Doctors and workers’ compensation attorneys agree that these cost savings have come as a steep price, which workers have had to pay. Denials have reportedly reached all-time highs. This is because the guidelines set by state administrators are simply too rigid and don’t keep pace with modern treatment methods.

In 2014, a survey conducted by the California Medical Association about the 2013 reforms showed that 67 percent of doctors reported difficulties getting treatment approvals and more than half said the greatest problem was the denial of medically necessary procedures, tests or services.

Workers Struggle to Get Care

Many injured workers who shared their stories with NBC said they have been stuck in the system for several years, are still hurting and not working. Many say the pain for them is not just physical. Workers say they have been frustrated not being able to work and not being able to provide for their families. One man who crushed his arm on this job and suffered nerve damage told NBC he still suffers from severe pain. His doctor had ordered a series of treatments including surgery to improve his condition. But, he said, medical reviewers denied 80 percent of those requests, leaving him on the road to permanent disability at age 48.

Of course, there is a process in place to appeal denials. However, an analysis of decisions by NBC found that medical reviewers uphold these denials nearly 90 percent of the time. Injured workers say they are tired of the red tape and roadblocks they have to face during this aggravating process. Some say they’ve even had suicidal thoughts because of it. In fact, a nurse who dealt with chronic pain and depression after an on-the-job injury committed suicide after her appeal for medical care was denied, the report states. Others say they are even denied basic pain relief aids such as heating pads.

Effort to Reform the System

Governor Jerry Brown last year signed SB 1160 authored by Senator Tony Mendoza into law. This new law, which is in effect now, will hopefully implement major reforms to the California Workman’s Comp claim system to fix the persistent delays and denials of medical care that has been plaguing workers. Senator Mendoza said this bill would transform the workers’ comp system so injured workers are guaranteed to receive timely and appropriate medical treatment and benefits within the first 30 days of the workplace injury.

The new law will also hopefully crack down on billions of dollars in fraudulent medical billing, which hurts injured workers as well. In addition, the law will require more oversight of insurance companies and third-party administrators. The medical treatment guidelines, which many physicians have complained about as overly rigid and outdated, will also be revamped under the new law.

Knowing and Understanding Your Rights

As we’ve already seen, seeking and getting the medical care and treatment you need after an on-the-job injury, can be a challenging proposition, given California’s complex workers’ comp system. Workers should understand that they are entitled to reasonable medical treatment to cure or relieve work-related injuries and illnesses. The doctors who treat you must follow treatment guidelines referred to as the medical treatment utilization schedule (MTUS).

If you pre-designated your personal physician or medical group before you were injured (this is a good proactive approach), you can have your regular doctor treat you for your work-related injures after you suffer the injury. Your employer may have a medical provider network or MPN, which is a group of healthcare providers selected by the employer or insurer to treat injured workers. These networks must also be approved by the state’s Division of Workers’ Compensation. Each MPN includes a mix of physicians specializing in work-related injuries and doctors with other areas of medical expertise.

After the first appointment, when you’ll see a doctor designated by a claims administrator, you are free to select another doctor within the network. Your employer may also have a health care organization or HCO, which is basically an organization certified by the DWC to provide managed medical care to workers. If and when you have a disagreement about your medical care, you may be evaluated by a qualified medical evaluator, who is basically a physician who must meet additional educational and licensing requirements including pass a test and participating in an ongoing workers’ compensation evaluation process.

Contacting an Experienced Lawyer

Please understand that your employer must pay for medical care if you have been injured on the job. You should never receive a medical bill, as long as you filed a claim form and your physician knows that the injury is work-related. If you have to travel to get treatment for your work-related injury, you can get reimbursement by filling out the medical mileage expense form for travel costs.

The best way to protect your rights is to contact an experienced California workers’ compensation lawyer who will go the extra mile to protect your rights and help you get the medical treatment and care you need to recover and get back to your job. If you have been injured on the job and are struggling to get benefits including medical care, call the ODG Law Group at 818-230-2428 for a free consultation and comprehensive case evaluation.

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