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Chapter 3. Medical Care
Who pays for my medical care?
Your employer pays for medical care for your work-related injury or illness, either through a workers’
compensaon 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 led a claim form 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 may be work-
related. This law is found in California Labor Code secon 3751(b).
What kind of medical care is available to injured workers?
California workers’ compensaon law requires claims administrators to authorize and pay for medical
care that is “reasonably required to cure or relieve” the eects of the injury. This means care that follows
sciencally based medical treatment guidelines.
Medical treatment guidelines used in California
The medical treatment guidelines currently being used in California are in the medical treatment ulizaon
schedule (MTUS) published by the Division of Workers’ Compensaon (DWC). The current MTUS includes
porons of the Occupaonal Medicine Pracce Guidelines, Second Edion, published by the American
College of Occupaonal and Environmental Medicine (ACOEM), as well as other guidelines. They also
include guidelines for acupuncture treatment, chronic pain treatment, and post-surgical treatment. The
MTUS is currently being updated.
The medical treatment guidelines are designed to help physicians give appropriate treatment. This
includes advising and guiding the injured worker on how to remain acve while recovering, and informing
the employer about the kinds of changes at work that are needed to promote recovery. Such changes
could involve dierent job assignments, reduced working hours, or other accommodaons that are safe
and appropriate for the parcular injury.
If your doctor recommends treatment that is not in the guidelines
Some injured workers have medical condions 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 sciencally based guidelines that are generally recognized by the naonal
medical community. (Some treatment guidelines, for example, are available online at the website of the
Naonal Guideline Clearinghouse: www.guideline.gov.)
If your case is seled with an agreement on future medical care
If you and the claims administrator seled your workers’ compensaon case with an agreement that you
will connue to receive medical care for your injury, the medical treatment guidelines and rules described
above sll apply to you. The guidelines and rules apply to all treatment, even in cases that seled before
medical treatment guidelines were added to workers’ compensaon law.
For ps on how to keep
your claim on track, see
p. 9. See also Chapter
10.
A Guidebook for Injured Workers 11
Limits on chiropracc, physical therapy, and occupaonal therapy visits
If your date of injury is in 2004 or later, you are limited to 24 chiropracc visits, 24 physical therapy visits,
and 24 occupaonal therapy visits for your injury (except for visits under the post-surgical treatment
guidelines above), unless the claims administrator authorizes addional visits in wring. Also, regardless
of your date of injury, you may be subject to other limits on these visits based on the medical treatment
guidelines described above.
When does my medical care start?
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 aer you le a claim form. While invesgang your claim, he or she must authorize necessary
treatment up to $10,000.
What should I do if the claims administrator does not authorize treatment
right away?
Speak with your supervisor, someone else in management, or the claims administrator about the law
requiring immediate medical treatment. This law is found in California Labor Code secon 5401(c). Ask for
treatment to be authorized now, while waing for a decision on your claim.
If the claims administrator won’t authorize treatment, use your own health insurance to get medical care.
Your health insurer will seek reimbursement from the claims administrator.
If you don’t have health insurance, try to nd a doctor, clinic, or hospital that will treat you without
immediate payment. They will seek reimbursement from the claims administrator.
To challenge the claims administrator’s decision not to authorize treatment, to request penales, or to le
a complaint, see Chapter 4.
Chapter 3. Medical Care
Did you know?
• Your employer is required to post informaon about your workers’ compensaon 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
wrien informaon 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 aect your benets.
• You have a right to have another person present during a medical examinaon or to tape record the examinaon. Note: You
should tell the doctor if you plan to tape record the examinaon.
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For non-emergency care, 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 organizaon (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 condions unrelated to work are allowed to predesignate their
personal physician or a medical group before injury. For informaon on how to predesignate, see Chapter
1. If you predesignated, you may see your personal physician or the medical group right aer 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. MPNs must
be approved by the Division of Workers’ Compensaon (DWC). An employer or insurer that has an MPN
must give you wrien informaon about the MPN.
If your employer or the insurer has an MPN, in most cases you will rst be treated in the MPN aer you
are injured, unless you predesignated.
If there is a health care organizaon (HCO)
An HCO is an organizaon cered by the DWC that contracts with an employer or insurer to provide
managed medical care for injured workers. Most employers and insurers do not have contracts with
HCOs. An employer or insurer that has a contract with an HCO must give employees a form prepared
by the Division of Workers’ Compensaon, DWC Form 1194, to allow them to choose whether to enroll
in the HCO. This form must be given to new employees within 30 days aer date of hire and to current
employees at least once a year. The form is in the California Code of Regulaons, tle 8, secon 9779.4,
and can be downloaded. (For instrucons on how to access the regulaons, see Appendix A.)
If your employer or the insurer has a contract with an HCO, in most cases you will rst be treated in the
HCO aer 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 rst treats you aer you are injured, unless you
predesignated.
Other situaons where you can choose who treats you right aer injury
Somemes an injured worker has a right to choose the primary treang physician even if he or she did not
predesignate:
• If your employer did not post required informaon about your workers’ compensaon rights and has
not oered treatment aer learning about your injury, you can go to your personal physician right aer
you are injured.
• If your employer or the insurer sends you to treatment that is completely inadequate or refuses
to provide necessary care, you can go to a physician of your choice. This does not have to be your
personal physician.
If you believe one of these situaons applies and you would like to be treated by your personal physician
or another physician of your choice, get help immediately to avoid a possible dispute about who can
choose the physician. Use the resources in Chapter 10.
Chapter 3. Medical Care
A Guidebook for Injured Workers 13
Can I switch to a dierent doctor for treatment?
Yes. However, your choices depend on whether you are being treated in a medical provider network
(MPN) or a health care organizaon (HCO) and whether you predesignated your personal physician.
Choices if you are being treated in an MPN
If you are being treated in an MPN, aer the rst medical examinaon for your injury, you are allowed
to switch to another doctor within the MPN, and you may switch again whenever it is reasonable to
do so. Your employer or the insurer must give you wrien informaon on how to do this and, starng
January 1, 2014, oer services to help you nd an available doctor. In most cases, you are not allowed
to switch to a doctor outside 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 me to another doctor
within the HCO. The HCO must give you a choice of physicians within 5 days aer you request a
change.
If you are covered by employer-provided health insurance, then 180 days aer your injury or illness
is reported to your employer, you are allowed to switch to a doctor outside the HCO. If you are not
covered by employer-provided health insurance, then 90 days aer your injury or illness is reported to
your employer, you are allowed to switch to a doctor outside the HCO.
When you switch to a doctor outside the HCO, the new doctor can be a medical doctor, osteopath,
psychologist, acupuncturist, optometrist, denst, podiatrist, or chiropractor. (A chiropractor may not
be your treang physician, however, aer you have received your maximum number of chiropracc
visits, as described on p. 11.) 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
medical care. You may switch again whenever it is reasonable to do so.
Choices if you are not being treated in an MPN or HCO and you did not predesignate
If you are not being treated in an MPN or HCO and you did not predesignate your personal physician,
you have a right to switch to a new doctor one me during the rst 30 days aer your injury or illness
is reported to your employer. However, the claims administrator is usually allowed to choose the new
doctor. But if you gave your employer the name of your personal chiropractor or acupuncturist in
wring before you were injured, you may switch to your chiropractor or acupuncturist upon request,
aer you rst see a doctor chosen by the claims administrator. (A chiropractor may not be your
treang physician, however, aer you have received your maximum number of chiropracc visits, as
described on p. 11.)
Aer 30 days, you are allowed to switch to a doctor of your choice if you sll need medical care and
your employer or the insurer sll has not created an MPN. The new doctor can be a medical doctor,
osteopath, psychologist, acupuncturist, optometrist, denst, podiatrist, or chiropractor. (A chiropractor
will be subject to the maximum number of visits described on p. 11.) 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 medical care. You may switch again whenever it is reasonable to do
so.
Chapter 3. Medical Care
14 Workers’CompensaoninCalifornia
Choices if you are being treated by a predesignated personal physician
If there is an MPN: If you are being treated by a doctor you predesignated and your employer or
the insurer has an MPN, you may switch to a new doctor within the MPN, and you may switch again
within the MPN whenever it is reasonable to do so. Your employer or the insurer must give you wrien
informaon about how to select a doctor within the MPN and, starng January 1, 2014, oer services
to help you nd an available doctor. However, your predesignated personal physician may refer you to
another doctor outside the MPN for consultaon or specialized treatment.
If there is an HCO: If you are being treated by a doctor you predesignated and your employer or the
insurer has a contract with an HCO, you may switch to a new doctor within the HCO. You may switch again
within the HCO and later to a doctor outside the HCO as described above, under “Choices if you are being
treated in an HCO.”
If there is no MPN or HCO: If you are being treated by a doctor you predesignated and your employer
or the insurer does not have an MPN and does not have a contract with an HCO, you may switch doctors
as described above, under “Choices if you are not being treated in an MPN or HCO and you did not
predesignate.”
How can I avoid problems in getting appropriate treatment?
Understand your primary treang physician’s treatment plan, and request copies of all medical reports
about your injury wrien by your primary treang physician and any specialists. These reports, which
the doctors are required to send to the claims administrator, describe the nature of your injury, causes of
the injury, necessary treatment, and types of work you can do while recovering. The doctor and claims
administrator are required to give you copies if you request them (except in some cases when the request
is for mental health records). If you have quesons about a parcular report, ask the doctor.
Chapter 3. Medical Care
