One of the benefits of the workers' compensation system is medical care. The steps that you take after you're injured in a job determines whether you'll receive the treatment that you deserve. The California workers' compensation system has established a detailed process that injured workers should follow while seeking medical care. That's why you should seek the help of an attorney to guarantee smooth medical treatment.

A reliable attorney will ensure that you get help from a reliable doctor and receive the benefits that you deserve. At The Workers Compensation Lawyer Law Firm, we are ready to provide professional assistance to clients injured in their Los Angeles, CA workplaces. Please schedule an appointment with us today for a detailed review of your case.

Types of Injuries in a Workplace

California's workers' compensation system covers any type of disease or injury that arises out of employment. According to the Labor Code Section 3208, there are two types of injuries in workers' compensation. These includes:

Specific Injuries

A specific injury is a type of injury that results from a specific type of incident that makes you miss work or require medical treatment. Some of the common specific injuries include the following:

  1. Motor Vehicle Accident

Motor vehicle accidents affect people who drive as part of their jobs and are exposed to inclement weather, negligent drivers, and faulty automotive equipment. These factors can cause car or truck accidents. Apart from being drivers, workers who spend most of their time around moving workers are also at risk of motor vehicle accidents. For instance, workers in a construction site might be hit by a tractor or a forklift while working.

  1. Slips and Falls

Several factors can cause slips and fall in workplaces, including wet floors, uneven cords, unstable walking surfaces, and poor lighting. A fall can lead to severe injuries, including spinal cord injury, traumatic brain injury, broken bones, and soft tissues damage.

  1. Falling from Heights

Falling from heights is the leading cause of workers' death in construction. Construction workers are at risk of falling from platforms, scaffolding, stairways, and other elevated surfaces. These falls often result from poorly built structures and improper use of safety equipment.

  1. Electrocution

Workers exposed to electric wires and cords are at risk of electrocution-related injuries. Faulty electric outlets can cause harm. Sometimes workers suffer electrocution when working around power lines or hitting underground power lines when digging.

  1. Overexertion

Holding, pushing, carrying, or throwing activities are the most common causes of overexertion injury. Overexertion can occur as a single injury or a cumulative injury. Single injuries result from a slip or trip that injuries the ligaments, tendons, or muscles.

  1. Struck by Objects

Being struck by an object falling from above, thrown by a person can cause severe injuries in a workplace. Falling, rolling, or swinging objects can cause blunt-force trauma like internal organ injuries, eye injuries, cuts, and bruises.

  1. Struck Against an Object

Workers who unintentionally run or get pushed into a stationary object like a window, door, vehicle, or machinery can injure their foot, neck, or knee. This type of accident is common in cluttered workplaces and has unclear markings of obstacles within the environment.

Cumulative Injuries

Cumulative injuries result from repetitive mental and traumatic physical activities that happen over a specific period. They result from repetitive insignificant movements, which would not likely cause an injury, but over time would cause an injury that requires medical treatment.

Cumulative traumas claim results from repetitive motions common in the following jobs, among others:

  • Secretaries
  • Stun people
  • Grocery store clerks
  • Hospital workers
  • Teachers

Examples of cumulative trauma injuries include:

  • Tendonitis
  • Carpal tunnel syndrome
  • Rotator cuff tendonitis
  • Tennis and golfer's elbow
  • Back injuries

Carpal tunnel syndrome and back injuries are the most common form of cumulative trauma injuries. Carpal tunnel syndrome occurs when the nerves of the wrist are compressed. They result in pain, tingling in hand, and numbness. It's more likely to affect secretaries in offices who frequently use computers in their jobs.

First Aid Medical Care in California's Workers' Compensation Claim

First aid medical care refers to any one-time treatment and other follow-up visits to observe minor scratches, cuts, splinters, or other minor industrial injuries, which ordinarily don't require medical care. This one-off treatment and follow-up visits to observe are referred to as first aid even when provided by registered professional personnel or physicians.

First aid treatment is unique since employers don't have to provide injured workers with the claim form or submit an Employer's First Report when first aid is administered to the injured worker. However, the physician rendering the first aid treatment must submit a Doctor's First Report to the employer's claim administrator.

When an employer considers a particular injury as first aid, it allows the employer to refrain from providing a claim form and begin the process of obtaining compensation benefits. Additionally, your employer may benefit from this injury since failure to report the injury may not affect their workers' compensation premium or reserves. Therefore, there are chances that your employer will not initially report the injury.

Further, according to OSHA regulations, occupation injury refers to any injury like a sprain, amputation, or fracture that results from instant exposure to a hazardous work environment. On the other hand, minor injuries are referred to as injuries that require first-aid treatment only. Minor injuries don't have to be recorded in OSHA loss. Therefore, according to OSHA Employer Safety Records, injuries categorized as "first aid" are advantageous to the employer.

If you receive First Aid, you should save all documents obtained from your treatment. You should also maintain the names of the co-workers and managers who witnessed the injury or to whom you reported the injury. You should also seek legal help to determine whether it's in your best interest to report the injury in a formal compensation claim form.

What You Should Know About Medical Provider Network in Workers Compensation

An injured worker in California cannot seek medical care from just any worker. Insurers and employers have established the Medical Provider Network (MPN) to control the cost of medical care to workers under the Workers' Comp System.

California employers can establish their MPN, which should give injured work access to medical treatment. The network should have enough doctors to treat common injuries in all geographical areas in California. MPN include:

  • Psychologists
  • Dentists
  • Acupuncturists
  • Podiatrists
  • Chiropractic practitioners

Every MPN should list their doctors online to allow injured workers to schedule appointments without waiting or their insurance company provide the information and cause significant delay.

All treatment in workers' compensation under the MPN follows specific treatment guidelines. These guidelines determine the frequency, duration, intensity, and appropriateness of all treatment modalities and procedures performed in compensation cases. These guidelines are intended to ensure that all injured workers receive a standardized level of care.

Doctors in the MPN should follow medical guidelines through a process referred to as Utilization Review. In this process, doctors send medical treatment requests to independent physicians who will approve, modify, or deny the treatment request.

MPN and Utilization Review doctors work together to direct the treatment process of an injured worker. MPN determines the doctor who will treat an injured worker, while the Utilization Review determines what kind of treatment the injured worker can receive.

Therefore, if employers raise issues about their treatment, they can only solve this through the Utilization Review process.

A treating doctor's opinion about an injury is a crucial aspect of a workers' compensation process. The treating doctors in the MPN determines the following:

  • If the worker has incurred an injury
  • If the injury is a cumulative trauma
  • Whether the injured worker has suffered temporary disability
  • Permanent disabilities
  • Permanent and stationary dates
  • Apportionment

The treating doctor directs the treatment procedure of an injured worker. They will determine whether the injured worker can work during temporary disability and the period that temporary leave should last. Treating doctors also issue opinions on whether the injured worker's condition has stabilized and the amount of permanent disability the worker has suffered. They also determine the dollar value of your treatment and whether the worker should seek medical help from a specialist.

MPN Notices and What You Should Now About Them

Employers must provide an MPN notice to an injured worker once they report an injury. The MPN notice includes the following:

  • How you can reach out to an MPN contact person for assistance in scheduling and finding appointments
  • A detailed description of the MPN services
  • How you can access the MPN directory
  • How you can access your initial medical care
  • Ways to choose an MPN doctor
  • What you can do when there's trouble scheduling an appointment
  • How you can change a physician within the MPN
  • Ways to find referrals to a specialist
  • How you can use your second and third opinion process
  • How you can receive an MPN independent medical review

Please note, regardless of the MPN doctor that you choose, you are eligible for mileage reimbursement. The mileage reimbursement covers your trip's doctor's appointments, pharmacies, physical therapy, and other related travels.

Choosing and Accessing MPN Doctors

Employers should arrange their worker's first appointment with MPN doctors. After the first visit, the employer should notify their workers how to access a list of MPN providers and their right to change their treating physicians.

An MPN should have at least three doctors in different specialties to treat common injuries within 15 miles or thirty minutes of all covered employers. It should also have specialists within sixty minutes or thirty miles of all covered employees.

Injured employees who don't find a doctor within their requirements can seek treatment outside the MPN. Treatment from an employer who doesn't meet this requirement is determined on a case-by-case basis.

Doctors outside MPN should follow the standardized treatment under the Workers' Compensation Treatment guidelines. They should also adhere to treatment requests through the Utilization Review and accept payment through the Workers' Compensation insurance companies.

Please note, injured workers can seek treatment from a doctor who has been removed from the MPN under the following condition:

  • Treatment for an acute condition for a minimum of ninety days of the injury
  • Treatment of a severe condition for a maximum of 12 months
  • Treatment for a terminal illness for the period that it last
  • Perform surgery for a maximum of 180 days

Seeking A Second or Third Opinion through MPN

Injured workers can seek a second or third opinion when they dispute their treating doctor's opinion and recommendation. The process of disputing the treating physician opinion include:

  • Notifying the employer that they are disputing their primary physician's opinion and would want to seek a second opinion
  • Select another doctor from the MPN to give the second opinion
  • Make an appointment within sixty days
  • Inform the insurance company about the second appointment

Insurance companies should provide a list of second opinion doctors and send all relevant medical documents to the selected doctor. Failure to make the appointment within sixty days after receiving the list means you have waived the right to dispute the first opinion. Doctors issuing the second or third opinion must issue their opinion within twenty days.

What You Should Know About Independent Medical Review

Injured workers can further seek an independent medical review if they dispute their diagnosis or treatment after receiving a second or third opinion. The independent doctor must follow through with the same standards outlined by the Workers Compensation system.

An independent review doctor usually reviews the injured workers' relevant medical documents, examines the injured worker, and performs the necessary diagnosis. The doctor will then issue a report within thirty days.

An independent medical review is an entirely different procedure. It deals with whether the treatment received by the injured worker is appropriate or not. It also determines whether the initial MPN doctor is an appropriate medical practitioner.

The independent review doctor will then send a report to the administrative director, who notifies the injured worker. The independent medical review doctor's opinion is referred to as the final opinion. If the independent doctor approves a previously denied treatment, the injured worker can seek treatment from another doctor, whether in or out of the MPN. This doctor should follow the treatment diagnosis guidelines.

Please note, no other examination can be used to resolve a diagnosis or treatment between an injured employee and the treating doctor. Therefore, it's unlikely for injured workers to seek another opinion after the Independent Medical Review due to the delay in receiving appropriate treatment.

An injured worker will most likely have to wait a minimum of thirty days to receive a second report from the start of the independent medical review process. This might require more time, owing to the time spent seeking a second or third opinion from MPN doctors. This is not practical for a worker with serious health issues.

How to Prepare for Independent Medical Review

You should remember that injured workers usually seek independent medical review to obtain information for the insurance company related to the extent and nature of the injuries, but not necessarily for treatment. Therefore, it's crucial to take this examination or review seriously to make the right impression. Here are a few steps you can follow when preparing for an independent medical review.

     1. Keep Your Appointment

Failure to attend an independent medical review can lead to the suspension of payment of your medical bills. Therefore, you must attend your appointment and arrive on time.

     2. Beware of What You're Getting Yourself Into

You should note that an Independent Medical Doctor exists only to give opinions about your medical care rather than your treatment. Therefore, this doesn't suggest that the independent medical doctor will be biased against you, but it's safe to say that the doctor isn't exactly on your side. Therefore, keep an eye on any indications that your injuries are attributed to pre-existing conditions, or you're not hurt as badly as you claim.

     3. Maintain Honesty in Whatever You Say

It's always recommendable to remain polite, cooperative, and faithful throughout the independent medical review process. Remember, the independent review doctor will mention any form of dishonesty in your report, which can significantly affect your compensation claim.

     4. Remain Organized

One of the best ways to remain confident during an independent medical review is to be clear with your medical history, injuries, and the effects of the injuries you suffered in your workplace. Here are some of the tips that can help you remain organized.

  • Your medical history
  • How the workplace injury occurred
  • When your injuries caused your the most pain
  • Treatment or medication that has been effective for you

What You Should Know About Out of State Medical Care in California Workers Compensation Case

Injured workers in California can seek medical care out of California when reasonable factors are associated with this decision. Reasonable factors mean that the decision to seek medical treatment out of state will benefit the injured worker by treating, curing, or reducing the pain associated with the injury.

Injured workers don't necessarily need to seek medical care from an MPN doctor while seeking treatment out of state. However, an injured worker should seek assistance from the insurance company when finding a doctor.

An injured California worker can seek treatment out of state due to several reasons. These reasons include:

  • The worker is injured outside California and required to seek treatment from there
  • The worker lives close to another state border with closer doctors
  • The worker moved to another state after incurring the injury
  • The worker needs to go back to his or her home country
  • The worker left California and requires unexpected treatment for the workplace injury
  • The injury requires treatment that's not available in California

 An injured California worker can also seek treatment out of state if the distance traveled is reasonable based on the situation of the injury. A reasonable geographic area would depend on the following factors:

  • The worker's place of employment, residence, and where the injury occurred
  • The availability of physicians in the medical field of practice and facility offering the treatment
  • The workers' medical history
  • The worker's primary language

If an injured employee meets these requirements, the decision to seek out-of-state treatment is regarded as reasonable.

How to Request Medical Care Outside California

An injured employee should start by asking their insurance company to authorize treatment outside California based on the above reasons. If the company approves the treatment, it means that it will cover all the expenses.

If the insurance company denies the request, this becomes a "self-procured" treatment. Insurance companies do not state how an injured worker will receive medical treatment or provide payment for out-of-state treatment with self-procured treatment.

Please note that most treating doctors don't prefer self-procured treatment since it's unclear how an injured worker will make the payment.

You should also note that travel is also included as an expense of your out-of-state treatment. Therefore, you can seek mileage reimbursement as part of your Workers' compensation benefit.

Seeking Medical Treatment when Your Claim is Denied

The insurance company making decisions about your work injury treatment in California can deny your claim for various reasons. In most cases, they often deny claims when advised by the MPN doctor or the independent medical review doctor.

In most denials, insurance companies follow a specific pattern. For instance, when the initial treating doctor recommends your medical treatment, the insurance company receives the recommendation, but the insurance adjuster disagrees with it.

Additionally, when an independent medical examiner makes a decision that agrees with the initial recommendation, this might easily have your claim denied.

Other factors that can make an insurance company deny your claim include:

  • They believe that the injury isn't work-related
  • You were under the influence of drugs or alcohol at the time of the injury
  • You missed your filing deadline
  • The treating doctor or Independent Medical Examiner doesn't believe that you require further treatment
  • You've reached your maximum medical improvement

The best way to guarantee compensation for your medical care is by filing an appeal. You should remember that the appeal process is complicated, and it's best to be handled by an experienced workers' compensation attorney.

Meanwhile, you can utilize the maximum $10,000 medical coverage allowed by the California workers' compensation system for injured workers whose claims are still in progress. The coverage is available for any medical expenses incurred and related to the work injury before the claim is accepted or denied.

Find a Workers Compensation Lawyer Near Me

It's recommendable to seek help from a workers' compensation attorney once you're injured at work. You need to find an attorney who's experienced and skilled enough to help you throughout your claim process. At The Workers Compensation Lawyer Law Firm, our experience in the California Workers' Compensation System guarantees the best legal services to  clients seeking compensation in Los Angeles, CA. For more information, call us today at 424-501-9228 and schedule an appointment.