MEDICAL TREATMENT OVERVIEW
Your employer pays for medical care for your work-related injury or illness, either through a workers’ compensation insurance policy or by being self-insured. The claims administrator pays the medical bills. 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.
MEDICAL TREATMENT FAQ
California workers’ compensation law requires claims administrators to authorize and pay for medical care that is “reasonably required to cure or relieve” the effects of the injury. This means care that follows scientifically based medical treatment guidelines.
Medical treatment guidelines used in California
The medical treatment guidelines currently being used in California are in the medical treatment utilization schedule (MTUS) published by the Division of Workers’ Compensation (DWC).
The medical treatment guidelines are designed to help physicians give appropriate treatment. This includes advising and guiding the injured worker on how to remain active while recovering, and informing the employer about the kinds of changes at work that are needed to promote recovery.
If your doctor recommends treatment that is not in the guidelines
Some injured workers have medical conditions requiring treatment that is not in the MTUS. If your doctor recommends treatment not in those guidelines, the claims administrator is required to pay for the treatment if it follows other scientifically based guidelines that are generally recognized by the national medical community.
Limits on chiropractic, physical therapy, and occupational therapy visits
You are limited to 24 chiropractic visits, 24 physical therapy visits, and 24 occupational therapy visits for your injury (except for visits under the post-surgical treatment guidelines above), unless the claims administrator authorizes additional visits in writing.
If it’s an emergency, your employer must make sure that you have access to emergency treatment right away. For non-emergency care, the claims administrator is required to authorize treatment within one working day after you file a claim form. While investigating your claim, he or she must authorize necessary treatment up to $10,000.
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, and whether you previously predesignated your personal physician or a medical group.
If you previously predesignated your personal physician or a medical group
Workers with health care coverage for conditions unrelated to work are allowed to predesignate their personal physician or a medical group before injury. If you predesignated, you may see your personal physician or the medical group right after you are injured.
If there is a medical provider network (MPN)
An MPN is a group of physicians and other health care providers who treat injured workers. An employer or insurer that has an MPN must give you written information about the MPN. If your employer or the insurer has an MPN, in most cases you will first be treated in the MPN after you are injured, unless you predesignated.
If there is a health care organization (HCO)
An HCO is an organization certified by the DWC that contracts with an employer or insurer to provide managed medical care for injured workers. If your employer or the insurer has a contract with an HCO, in most cases you will first be treated in the HCO after you are injured, unless you predesignated.
If there is no MPN or HCO
If your employer or the insurer does not have an MPN and does not have a contract with an HCO, in most cases the claims administrator can choose the doctor who first treats you after you are injured, unless you predesignated.
DID YOU KNOW?
- Your employer is required to post information about your workers’ compensation rights, including the right to predesignate your personal physician in case of job injury.
- If your employer or the insurer created a medical provider network (MPN), the employer or insurer is required to give you written information about rights, procedures, and services while being treated within the network.
- You have a right to request and receive copies of all medical reports that affect your benefits.