Under California and Longshore workers' comp laws, an injured worker has the right to receive medical care that is reasonably required to cure or relieve the effects of injury, at the expense of your employer. This treatment includes all necessary diagnostic, surgical, chiropractic, acupuncture, and other hospital treatment along with any necessary nursing care, medication, crutches, orthotic and prosthetic devices, and other medical services.
Under California law, after an injury, within one working day of filing your claim, even while the claims adjuster reviews your claim to decide whether to accept or deny your claim, you are entitled to immediate initial medical care up to a cost of $10,000.00.
If your claim is then denied, you will need to file for a hearing at the Workers' Compensation Appeals Board for State claims or the OWCP for Longshore claims, in order to fight for further medical treatment.
If your claim is accepted, then you have the right to select a doctor to be your Primary Treating Physician (PTP). Usually, the insurance company will have a network of doctors established, a Medical Provider Network (MPN) from which you must choose your PTP.
If the claims examiner happens to dislike the doctor that you selected, you may be sent to a Qualified Medical Examiner (QME) for a second opinion on behalf of the insurance company, or you may be offered an Agreed Medical Examiner (AME).
An AME is a doctor selected jointly by you and the insurance company. Because this selection requires participation by the injured worker, California law only allows this option if the injured worker is represented by an attorney in order to protect injured workers from getting tricked into selecting an unfavorable AME by unscrupulous insurance adjusters.
Selecting your PTP is one the most important decisions you will make during the course of your claim. Not only do you want to receive the best medical care but also, most of your other benefits will be based on the opinions and reports from your PTP. Your PTP will also determine if and when you can go back to work and in what capacity.
Selecting the correct PTP is only half the battle in getting the necessary medical care, however. Once you have selected your doctor and the doctor recommends an appropriate course of medical treatment for you, under California law, the insurance company then has the right to submit these recommendations for an outside review before they agree to pay for the treatment.
This review process is called "Utilization Review" (UR) and is conducted either by the insurance company itself or by an outside company that is paid by the insurance company. Therefore, it is not uncommon for a UR review to result in a denial of treatment by the insurance company.
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