Maison Law represents victims of work-related accidents in California. If you or a loved one has been denied medical treatment through workers’ compensation, you may be able to file a lawsuit to get the treatment you need, as well as compensation for the damages you’ve suffered. Contact the workers’ compensation attorneys at Maison Law today for a free consultation and evaluation of your workers’ compensation claim.
Reasons Your Medical Treatment is Not Being Authorized By Workers’ Compensation
Workers’ compensation in California has unfortunately become over-regulated and unnecessarily complicated over the years when it comes to approving and denying treatment. The following are examples of how workers’ compensation may fail to authorize your medical treatment after a work-related injury:
- The injury is denied: workers’ compensation will not authorize any treatment until the injury is confirmed by a neutral doctor. A new neutral doctor is an agreed-upon medical doctor between you and workers’ compensation.
- The body part is denied: workers’ compensation may approve treatment for one body part, but not multiple parts of the body. Only if an agreed-upon, medical professional certifies you have multiple injuries on your body, they will not approve treatment.
- Your treating physician is denied: In California, each workers’ compensation insurance carrier has the right to contract with a specific Medical Provider Network. You will have to select and be treated by a physician within that network.
- Request for medical authorization is denied: your primary treating physician must make all requests for your medical treatment and prescriptions using a “Request for Authorization Form.” Failure to submit this form will result in the denial of medical treatment. Even if your treating physician submits this form, treatment can still be denied if workers’ compensation does not see the reason for the treatment.
- Utilization review: If workers’ compensation denies an authorized request for treatment, 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 review affirms the denial, they must submit the appropriate medical guideline upon which their opinion is based.
- Independent Medical Review: Within 30 days of receiving a receipt of a Utilization Review Determination denial, you can request an Independent Medical Review to be performed by a company named Maximus with whom the State of California has contracted to handle these specific situations. Maximus will have 15 days to determine if the case is eligible for review and 30 days to issue a written decision as to whether or not the request for treatment should be authorized.
What is Maximum Medical Improvement
After suffering severe injuries at work, you will receive medical care through worker’s compensation. Your treating physicians will try to get you back as much of your bodily function as possible so you can return to work. In the course of treatment, if your physician sees that you’re not getting any better, while you’re not getting worse, they may find that you’ve reached the point of Maximum Medical Improvement (MMI).
Once you’ve reached MMI, your ability will determine if you can return to work on a restrictive basis or if you’re ready to completely return to your regular duties. Also, your employer will consider your physical restrictions before deciding to offer you “modified work.” Modified work means you will only be required to do a portion of your usual duties. If modified work is unavailable for your specific job, then your employer may choose to offer you “alternative work.”
This equates to a different type of work with the same rate of pay and employment location. Maximum Medical Improvement can play an important role in your worker’s compensation lawsuit because it can determine if you’ve suffered permanent disabilities or damage to your life due to your work-related injury.
Know Your Medical Treatment Authorization Rights
Each worker has an opportunity to use their own doctor if they were injured in a work-related accident, but only if the doctor’s identifying information was given to the employer prior to the injury. If there was no pre-designation of a primary treating physician before the injury, there are still certain exceptions in which you can still choose your own doctor. These exceptions include:
- If your employer did not post the required information about workers’ compensation rights and did not offer treatment after learning about your injury
- If your employer or claims administrator sends you for treatment that turns out to be insufficient or fails to give you care at all
If either of these scenarios applies, then it is recommended to contact a workers’ compensation attorney to ensure you get the proper care.
How Can an Attorney Help With Medical Treatment Authorizations?
A workers’ compensation attorney can help resolve disagreements about medical treatment. If you decide to challenge the medical treatment you receive or if you feel it is inadequate, an attorney can advocate on your behalf against workers’ compensation. The process will depend on whether you are being treated by a doctor within the Medical Provider Network (MPN) of workers’ compensation.
When going through workers’ compensation, you can get up to two more doctors’ opinions within the MPN. If you can’t reach an agreement with either of these doctors within 60 days, then a workers’ compensation attorney can help you arrange for an independent medical review with the California Division of Workers’ Compensation.
Contact a Workers’ Compensation Claims Lawyer in California
If you or a loved one has been injured at work and have been under-compensated by workers’ compensation or denied treatment, the attorneys at Maison Law can help. Workers’ compensation claims can be complicated matters, but our attorneys have years of experience of getting work accident victims the compensation and medical care they need. Contact Maison Law today for a free consultation and case evaluation. No upfront money is required for our services and we don’t get paid unless we win your case.
