By Seth Merrick, Attorney, Rains Lucia Stern, PC
Most people don’t care about whether their doctor writes a good report or treatment request or how much they know about the ins and outs of workers’ compensation laws and regulations. They are looking for the best doctor, period, and nothing else really matters. In workers’ compensation, however, you cannot afford to ignore these concerns. In fact, ignoring them when choosing a doctor in workers’ compensation can mean that the treatment you do get (if you actually get it) is inadequate and significantly delayed.
The recent changes in California laws (and an increasingly skeptical public) have created an environment wherein injured workers are forced to consider far more than a doctor’s ability to practice medicine when seeking medical treatment. A new almost hybrid form of treating physician has emerged where a doctor’s ability to write reports that conform to various regulations can be as useful as their ability to administer the treatment itself.
In workers’ compensation, whether treatment is authorized often depends on whether the physician requesting it adhered to guidelines set forth in endless regulations rather than medical necessity. If done correctly, an initial report that properly phrases a request can help avoid the delays inherent in the lengthy and arduous denial process driven by a bureaucratic analysis called Utilization Review (“UR”).
If a request is denied by UR, the next step is for a physician to initiate the appeal process (something that an injured worker will know nothing about). The appeal process requires that your physician appeal the denial of the treatment and set forth why the treatment being denied conforms with medical AND legal parameters. Many physicians will not do these appeals unless specifically asked, and even then they can be insufficient to successfully appeal the denial. Both the request and the appeal require significant knowledge of workers’ compensation treatment guidelines and an ability to integrate these into their reports. In other words, physicians are required to act as a doctor AND lawyer just to get the treatment needed to heal and to get back to work.
Not only is this a burden on participating physicians by asking them to do more work to get less accomplished (no wonder doctors are leaving workers’ compensation), the injured worker continues to suffer throughout the delayed process. In addition to being in pain and discomfort from their injury, injured workers must also deal with the frustration and fear of knowing that the treatment necessary to getting them healed and back to work is being denied through reliance on arcane regulations and rules rather than looking at medical necessity.
The best workers’ compensation treating physicians can greatly increase the amount of care an injured worker receives and greatly reduce the delays inherent in receiving the treatment. When an injured worker is more completely restored in a shorter amount of time they suffer less physical and emotional pain while getting back to work more quickly and protecting their careers.
You do not need to hire an attorney just to find the right physician for your injury. Any attorneys representing public safety officers should gladly provide this type of guidance for free. The great majority of injuries do not require full representation. In fact, if you ask for help early enough in the process you won’t need more than some guidance and advice on issues such as the right physician, requesting a QME panel and other minor issues. These can be handled by a few phone calls and emails with an attorney without the need for payment or formal representation. Make sure you ask for advice early on (even if you don’t think you need it) so you can formulate the best plan for getting the treatment you need to recover from your injury as fully as possible.
Call RLS and take advantage of our expertise in such matters. RLS has worked with and has access to hundreds of physicians and specialists who can help you get the right treatment in a timely manner. Rather than worry about denied treatment and benefits, you can focus on healing and getting back to work (and keep your hard-earned money to yourself!).
Seth Merrick is the lead workers’ compensation attorney for Rains Lucia Stern, PC.
Please Note: Pursuant to Labor Code Section 5432(a), making a false or fraudulent workers’ compensation claim is a felony subject to up to 5 years in prison or a fine of up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment and fine.
