Need Medical Care After a Work-Related Injury or Illness? There’s a Bureaucracy for That
Filing for workers’ compensation benefits is only the beginning. Depending on the severity of your condition, you may need medical care and rehabilitation for months or years. Workers’ compensation carriers want to keep premiums low, so they try to save money by using a costly system of micromanaging treatment decisions. How much trouble a worker will have getting through the system varies, but having a workers’ compensation attorney can help you prevent and resolve problems if they arise.
With more than thirty years of experience, the Inland Empire workers’ compensation lawyers at Castillo & Associates have the skills to handle the complex legal, medical, and insurance challenges that can come with California workers’ compensation claims. If you are injured at work, contact us today for more information about your rights and legal options.
Injured Workers Are Stuck Between California’s Workers’ Compensation System’s Conflicting Goals
Ideally, all the parties involved in the system should get what they want:
- Workers should get the best, most effective treatment without needless delays so they can return to work and their lives as quickly as possible
- Employers should pay reasonable workers’ compensation insurance premiums
- Insurers should want employees and employers to reach their goals while making fair profits for their shareholders
There are many obstacles to this working like clockwork, including how insurers manage workers’ healthcare. Thanks to state rules and regulations, insurers can micromanage a worker’s treatment to prevent fraud and waste.
This can result in workers not getting the care they need when they need it and healthcare professionals spending their limited time and energy dealing with a bureaucracy that looks over their shoulders and second-guesses their decisions.
What is Utilization Review?
If you’re injured at work, you’re entitled to necessary and reasonable medical treatment to cure or relieve your injury. Utilization review (UR) is a process used by insurers’ claims administrators and employers to review treatment decisions and decide if they’re medically necessary. State rules spell out how UR should be conducted.
Employers and administrators engage in UR because they can decide if the medical treatment proposed by your physician meets the state’s medical treatment guidelines (the Medical Treatment Utilization Schedule (MTUS)). If it does, they should approve and pay for it. If they think the proposed treatment does not, a physician must review the case and decide if it should be approved.
What is the Medical Treatment Utilization Schedule (MTUS)?
The MTUS is a set of regulations with medical treatment guidelines and rules for deciding what qualifies as reasonable and necessary medical care. It is based on evidence-based medicine, so decisions should be made based on the best available evidence.
The MTUS details treatments proven to cure or relieve work-related injuries and illnesses. It lays out:
- Treatments that are believed to be effective for specific injuries
- How often the treatment should be provided
- The extent of the treatment, and
- Other details
Doctors and claims administrators must use the MTUS to decide if a treatment is medically necessary.
What is an independent medical review (IMR)?
If the carrier wants to change or deny a proposed treatment as not medically necessary, the claims administrator must inform you, your workers’ comp attorney, and your doctor in writing and state the reasons why. If you disagree with the decision, the dispute will be resolved by physicians through an IMR. There are forms to be filled out and deadlines to meet to get an IMR.
If you disagree with the IMR, you can ask for reconsideration based on new information that’s come up since it was done or if important evidence is overlooked. There may also be legal or procedural reasons to challenge the IMR’s findings with the Workers Compensation Appeals Board.
The IMR process is meant to be a quick, non-judicial way to resolve disputes about your medical treatment. The state chose Maximus as the independent medical review organization responsible for conducting IMRs. The company contracts with medical professionals who perform IMRs, and they are supposed to meet qualification and conflict of interest standards.
Speak With an Experienced California Workers’ Compensation Lawyer Today
If you’re injured at work or have a work-related disease, we can help you file for workers’ compensation benefits or represent you if your request is denied. Castillo & Associates will work to get you the best medical care possible so you can focus on recovery, your family, and returning to work.
Castillo & Associates’ team of workers’ compensation attorneys in Inland Empire have the skills to handle the complex legal and insurance challenges that come with California workers’ compensation claims. If you are an injured worker, fill out our confidential contact form or call us today at 800-497-9774 for more information about your rights and legal options.
Attorney Domingo Castillo handles workers’ compensation, personal injury, family law & immigration throughout Southern California from our 5 offices: Indio, Pomona, Riverside, San Diego & Cathedral City. We help clients file injury claims, obtain residency & citizenship, and we assist families through divorce, child custody and all family law matters.
