When you are injured at work in Los Angeles, your employer should help you take steps to get the medical attention you need to address your injury or illness. However, some employers take advantage of employees who do not know or understand California’s workers’ compensation system. To avoid that type of situation, you need to be proactive in getting medical attention after a work injury.
In California, an employer should “accept” your workers’ compensation claim if your injury was at work or occurred while you were performing work activities. When an employer accepts a claim, that means that their insurance company will pay for your medical treatment to address the injuries, along with other benefits.
When your treating doctor wants to perform a treatment, such as surgery, the medical professional must ask the employer’s insurance company for permission. They will submit an RFA or “Request for Authorization.” The RFA should include:
Whether a treatment is reasonably and medically necessary will often depend on looking to very specific treatment guidelines for conditions like yours. These guidelines are specifically set out in the Medical Treatment Utilization Schedule (MTU) or the American College of Environmental Medicine (ACEM). The guidelines will specifically set out what the doctor needs to show to prove that the treatment is necessary for your condition.
If an RFA is denied, then you have two options. First, you can request an Independent Medical Review or IMR. In this process, a third-party doctor will review your situation and provide an opinion about whether the recommended treatment is reasonable and medically necessary. However, this process is not all that effective. Thankfully, you have a second option if a treatment request is denied.
The second option is based on the court’s jurisdiction. There must have been a denial of care or an untimely denial of care (more than five business days or more than 72 hours in an emergency situation) to get the court’s jurisdiction. If this occurs, you may have the opportunity to appear in front of a judge to talk about your medical condition and request the suggested medical care.
When you are in front of the judge, you and your attorney will still have to prove that the treatment is reasonable and medically necessary. That means that you must show that the treatment is in compliance with the MTU or the ACEM.
A proactive approach can go along way in a medical treatment denial situation. In many cases, a treating doctor does not understand the standards they need to meet to ensure that your care is approved. Your attorney can speak with your doctor about the standards and provide information and guidance to the doctor about how the RFA should be presented. Simply phrasing things differently and providing a bit more information can be very helpful if your medical treatment request has already been denied once.
The Law Offices of Michael Burgis and Associates can help with this process. Learn more by contacting our firm to get more information or to set up a free consultation.