As an injured worker, you have the right to receive medical treatment to cure or relieve the effects of your injury. This treatment includes all necessary diagnostic, surgical, chiropractic, acupuncture, or other hospital treatment along with any necessary nursing care, medication, crutches, orthotic and prosthetic devices, and other medical services.
Within one working day of reporting your injury, while the claims adjuster reviews your claim, you are entitled to immediate emergency medical care up to a cost of $10,000.00.
If your claim is denied, then you will need to file for a hearing at the Workers’ Compensation Appeals Board in order to fight for further medical treatment.
If your claim is accepted, then you have the right to select a Primary Treating Physician (PTP). Selecting your PTP is one of the most important choices you will have to make in your worker’s compensation claim because both your medical care and all of your worker’s comp benefits will be based on the opinions of your PTP.
If the insurance company has established a network of workers comp doctors called a Medical Provider Network (MPN), you may be required to choose your PTP from the MPN.
If the claims examiner dislikes the opinions of your PTP, you may be sent to a Qualified Medical Examiner (QME) to get a second opinion for the insurance company, or you may be offered an Agreed Medical Examiner (AME).
Beware, if you have no disagreement with your PTP, you are not obligated to request a QME yourself, as some claims examiners may lead you to believe.
An AME is a doctor selected jointly by both you and the insurance company for a second opinion. The law only allows this option if you are represented by an attorney in order to protect injured workers from getting tricked into selecting an unfavorable AME by unscrupulous insurance adjusters.
Selecting the right PTP is only half the battle in getting necessary medical care. Once you have selected your doctor and the doctor recommends a course of medical treatment, the insurance company then has the right to review these recommendations 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. It is not unusual, therefore, for a UR review of the treatment recommended by your own doctor to result in a denial of that treatment by the insurance company.
