California Workers’ Compensation Law provides that the injured worker is entitled to all reasonable and necessary medical care to cure or relieve the effects of the industrial injury. However, recent changes to the workers’ compensation laws have significantly limited the type and scope of that medical care.

Beginning January 1, 2005, employers have the option of setting up “medical provider networks,” referred to as MPNs, for the purpose of providing medical care for work-related injuries. If the employer or insurance company does set up such a network, the injured worker must choose a physician from within that network. No longer can an injured worker simply choose his or her own treating physician.

In some limited situations, an injured worker may “pre-designate” a physician he or she wishes to treat with for a work-related injury before such an injury occurs. However, an injured worker can only do so if the employer has provided health coverage for non work-related injuries and then the pre-designated physician must be the injured worker’s regular treating physician who already maintains the worker’s medical records and the physician must agree to be pre-designated.

Moreover, one of the major changes in treatment passed by the Legislature under the guise of “workers’ compensation reform” is that treatment provided by the injured worker’s doctor must meet national guidelines as to pre-approved types of treatment for various types of injuries. These are known as ACOEM Guidelines for the American College of Occupational and Environmental Medicine. In other words, these treatment guidelines become the standard to which the treating physician must adhere in providing medical care to his or her patients for work-related injuries. Overcoming these guidelines (if your treating physician recommends treatment outside of the guidelines), is possible but difficult and your treating physician will have to show why the treatment he or she is recommending, if it is outside the scope of the guidelines, is scientifically based and more persuasive than the existing guidelines.

The treatment guidelines, called the ACOEM Guidelines, undoubtedly will make it more difficult for injured workers to obtain the necessary treatment recommended by their treating physicians.

Moreover, there are significant new changes in the law for injuries occurring after January 1, 2004 which restrict the amount of physical therapy, occupational therapy, and chiropractic care available to injured workers. Each of these different types of treatment, that is, physical therapy, occupational therapy and chiropractic care, is limited to 24 visits per injury. For those workers needing long-term care, this may cause severe hardship.

Additionally, the new “reforms” added special review provisions for any request for spinal surgery. Injured workers can expect that insurance companies will object and request a second opinion review of any request for spinal surgery, which in many cases may cause a delay even if the injured worker ultimately prevails on the need for surgery.

Please remember that the law provides for all “reasonable and necessary” medical care. What is reasonable and what is necessary is often in dispute with insurance companies and it is often necessary to involve the Workers’ Compensation Appeals Board over medical disputes if the insurance company will not provide medical treatment.

If the worker needs medical treatment and the insurance company refuses to give it, we suggest that the worker use his or her own health coverage to provide that treatment while the issues are being litigated at the Workers’ Compensation Appeals Board. In other words, the law indicates the worker’s own health plan or coverage must provide the treatment to the limits of its coverage if the treatment is being denied by the workers’ compensation carrier. The health plan can then file a “lien” in the case seeking reimbursement from the workers’ compensation carrier if the worker prevails at the Workers’ Compensation Appeals Board.

The Sacramento Workers’ Compensation Attorneys of Bowman & Associates serve clients across Northern California. If you or someone you know have questions regarding Medical Treatment in your Workers’ Compensation case, contact an experienced Workers’ Comp. Attorney in Sacramento today for your free initial consultation.

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