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  1. #1
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    Default How to Get Worker's Comp Insurance to Authorize Treatment on a Denied Claim

    Its been well over a year ive been off work, the IC for my employer has denied the claim right off the bat as a result of my employer claiming the the workplace injury was not a result of me performing my duties at work. Since then i have been through three different WC law firms trying to find on that actually knew what was going on with my case when i called them. I have been going to a Orthopedic doctor as my AME, whom has been operating on a lien. I am not AT ALL happy with the treatment im being given at what appears to be a workers comp mill. Narcotics and muscle relaxers are the main treatment there, and their physical therapy is a joke (lightly rubbing over a herniated disk). Ive repeatedly asked my attorney for another doctor, but he denies having any other doctor to send me to. Even though he barely speaks english, Ive tried to ask this doctor to send me to a chiropractor and for spinal decompression but he has refused.

    Ive called on my own several other doctors in the area, but they refuse to see me on a lien, and they can not treat me without the insurance companies approval. I have a AOE/COE hearing coming up in two months that i expect to be decided in my favor. Once this takes place, will the IC then be compeled to approve my claims for treatment, allowing me to see a real doctor?

  2. #2
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    Default Re: When Will Ic Be Forced to Authorize Treatment on a Denied Claim

    Quote Quoting snowycali View Post
    Its been well over a year ive been off work, the IC for my employer has denied the claim right off the bat as a result of my employer claiming the the workplace injury was not a result of me performing my duties at work. Since then i have been through three different WC law firms trying to find on that actually knew what was going on with my case when i called them. I have been going to a Orthopedic doctor as my AME, whom has been operating on a lien. I am not AT ALL happy with the treatment im being given at what appears to be a workers comp mill. Narcotics and muscle relaxers are the main treatment there, and their physical therapy is a joke (lightly rubbing over a herniated disk). Ive repeatedly asked my attorney for another doctor, but he denies having any other doctor to send me to. Even though he barely speaks english, Ive tried to ask this doctor to send me to a chiropractor and for spinal decompression but he has refused.

    Ive called on my own several other doctors in the area, but they refuse to see me on a lien, and they can not treat me without the insurance companies approval. I have a AOE/COE hearing coming up in two months that i expect to be decided in my favor. Once this takes place, will the IC then be compeled to approve my claims for treatment, allowing me to see a real doctor?
    Did you ever go to a QME or AME to determine if your injury is work related? That is the process in our state, if your claim is denied. They are back logged at least 5 months with providing a panel QME, and sometimes longer. That may be your situation, and not your attorney's fault.

    You need to find out if your insurance carrier/employer has a MPN Medical Provider Network and if so how to access it. You can contact The Medical Unit and ask for assistance finding your MPN if your IC has one. If you have a medical provider network you can try to find a doctor who will treat you on a lien, which may be difficult.

    The problem you have is your claim is denied. That means the insurance carrier does not have to continue treating it after a certain amount. It may be difficult to find someone to treat on a lien. Again, I would find out if this is the issue. This may be why your attorney is stating there is no other doctor to send you to (unknown and I suggest asking your attorney)You have the right to use your private insurance if you have private insurance as this is a denied claim.


    This is a good link that will help with your questions.
    http://www.dir.ca.gov/DWC/WCFaqIW.html#5

    "
    Q. The claims administrator hasn't accepted or denied my claim yet, but I need medical care for my injury now. What can I do?

    A. The claims administrator is required to authorize medical treatment within one working day after you file a claim form with your employer, even while your claim is being investigated. The total cost of the treatment provided while your claim is being investigated is limited to $10,000. If the claims administrator does not authorize treatment right away, speak with your supervisor, someone else in management or the claims administrator about the law requiring immediate medical treatment. Ask for treatment to be authorized now, while waiting for a decision on your claim."


    Q. What is a medical provider network?

    A. A medical provider network (MPN) is a group of health care providers set up by your employer's insurance company and approved by DWC's administrative director to treat workers injured on the job. Each MPN includes a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. If your employer is in an MPN your workers' compensation medical needs will be taken care of by doctors in the network unless you were eligible to predesignate your personal doctor and did so before your injury happened.

    Q. What is a health care organization?

    A. A health care organization (HCO) is an organization certified by the DWC to provide managed medical care to injured workers.

    Q. What is a primary treating physician (PTP)?

    A. Your primary treating physician (PTP) is the physician with the overall responsibility for treatment of your injury or illness. Generally your employer selects the PTP you will see for the first 30 days, however, in specified conditions, you may be treated by your predesignated physician or medical group. If a physician says you still need treatment after 30 days, you may be able to switch to the physician of your choice. Different rules apply if your employer is using an HCO or a medical provider network (MPN).

    Update image Q. What does predesignating a personal doctor involve?

    A. This is a process you can use to tell your employer you want your personal physician to treat you for a work injury. You can predesignate your personal doctor of medicine (M.D.) or doctor of osteopathy (D.O.) only if the following conditions are met:
    1.A written notice predesignating the employee's personal physician or medical group is given in writing to the employee's employer prior to the date of injury for which treatment is sought and the notice includes the physician's name and business address;
    2.The employee has healthcare coverage for non-occupational injuries or illnesses on the date of injury in a plan, policy or fund; and
    3.The employee's personal physician or medical group agrees to be predesignated prior to the dates of injury.

    The DWC has a form for predesignating a personal physician on the forms page of its website.

    Update image Q. I would like to be treated by my personal chiropractor or acupuncturist. How does that work?

    A. If your employer or your employer's insurer does not have a MPN, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. There is a form you can use called the notice of personal chiropractor or personal acupuncturist. After your claims administrator has initiated your treatment with another doctor during the first 30 day period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist.

    If you were injured on or after Jan. 1, 2004, a chiropractor cannot be your treating physician after 24 chiropractic visits. Once you have received 24 chiropractic visits if you still require medical treatment, you will have to select a new physician who is not a chiropractor.

    Q. Does the 24 cap on chiropractic visits apply to all cases?

    A. No. The 24 visit cap does not apply to injuries that occurred before Jan. 1, 2004. Also, the cap does not apply if your employer authorizes additional visits in writing. Additionally, the cap does not apply to visits for certain postsurgical physical medicine and rehabilitation services.
    Last edited by kelly38; 08-19-2013 at 01:44 PM.

  3. #3
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    Default Re: When Will Ic Be Forced to Authorize Treatment on a Denied Claim

    I don't think you're reading the question i posted.

    The claim is denied.

    The treating physician is a AME.

    The case is over a year old, unless you can provide me with a doctor that will treat on a lien i have given up on that.

    What effect will the decision of the AOE/COE hearing have on my ability to go see a real doctor of my choice.

    They are denying the case, who is on their MPN is IRRELEVANT until they are compelled to approve treatment, im asking how to make that happen.

  4. #4
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    Default Re: When Will Ic Be Forced to Authorize Treatment on a Denied Claim

    Sorry about the above. I cut and pasted more of the page on the link as intended. That link clearly states what to do when your claim is denied.

    I read your questions and provided the above info. This system in California can be very confusing.

    Is does not matter if your treating doctor is an AME or not. My treating doctor is an AME. He did not make the determination if my injury is work related or not, even though he believed it to be. I was seen by an agreed upon doctor (AME) just to determine if my injury was work related.

    You will need to be seen by a QME or AME to determine if your injury is work related. Has that happened? Where you evaluated by a doctor just on the issues of AOE/COE other than your treating doctor? That answers your question above on HOW to get your injury accepted, that is determined by a QME or AME evaluation. If the defense objects to that report that states the injury is work related, they can depose the AME/QME and/or take the issue to a judge, and so can your attorney if the opposite occurs.

    If the QME/AME decides your injury is work related, and the defense does not try to fight the decision, then you will not have to be treated on a lien. That will open up a lot more options to get a doctor to treat you.

    I suggest contacting an I&A officer at the WCAB your case is located at if you are having problems with your third attorney. They should be able to answer these questions.
    Last edited by kelly38; 08-19-2013 at 02:04 PM.

  5. #5
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    Default Re: When Will Ic Be Forced to Authorize Treatment on a Denied Claim

    You will need to be seen by a QME or AME to determine if your injury is work related. Has that happened? Where you evaluated by a doctor just on the issues of AOE/COE other than your treating doctor?
    Yes, the AME determined it is work related.

    f the QME/AME decides your injury is work related, and the defense does not try to fight the decision, then you will not have to be treated on a lien. That will open up a lot more options to get a doctor to treat you.
    He has, and they will fight it. Is this not what a AOE/COE hearing is for?
    Do you know if your IC has an MPN?
    Yes, since im represented, they will not give me any information on it because i've retained counsel, and my counsel never does anything i ask him to.

    Which is irrelevant because i cant see anyone on theyre network because my claim is DENIED. Are you saying i should be able to see doctors on their MPN with a denied claim??

    Though im not asking to see anyone on their MPN, I want a real doctor of my choosing, if i wanted handfulls of Vicodin, then ill see someone on their MPN.

  6. #6
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    Default Re: How to Get Worker's Comp Insurance to Authorize Treatment on a Denied Claim

    - - - Updated - - -

    Your first question stated if the judge orders your injury is work related, will I be able to see a real doctor. That is why I asked if you have an MPN. It is relevant as if the judge determines your injury is work related and if you have an MPN then you need to pick a doctor within the MPN.

    Quote Quoting snowycali View Post
    Yes, the AME determined it is work related.

    This AME is not your treating doctor right? If it is not your treating doctor and a separate doctor picked by both parties to determine if your injury is work related, then I can only assume that is what your hearing is for. You wrote in your first post you are going to your AME orthopedic doctor for treatment on a lien. This is confusing as an AME does not treat patients, and is there for examinations. They could recommend treatment previously before Sb 863.

    Your attorney would be the best one to respond to these questions as he knows the specifics to your case and what your hearing is for

    They should have given you info of an MPN regardless if they have one. The medical unit can look up your employer/IC and find out the MPN if they have one and how to access it. Do a search for their number on the link I provided. This is something you will need IF it is determined your injury is work related, and you wish to switch doctors. If you cannot find another doctor to treat you on a lien, then you will have to wait until the judge decides your injury and THEN you can pick a different doctor within your MPN. You questions are getting confusing as you stated you asked your attorney and employer for your MPN and was not provided it, and I just wrote to you how you can get access via medical unit, and then you state it is irrelevant?


    He has, and they will fight it. Is this not what a AOE/COE hearing is for?


    Yes, since im represented, they will not give me any information on it because i've retained counsel, and my counsel never does anything i ask him to.

    Which is irrelevant because i cant see anyone on theyre network because my claim is DENIED. Are you saying i should be able to see doctors on their MPN with a denied claim??

    Though im not asking to see anyone on their MPN, I want a real doctor of my choosing, if i wanted handfulls of Vicodin, then ill see someone on their MPN.
    This AME is not your treating doctor right? If it is not your treating doctor and a separate doctor picked by both parties to determine if your injury is work related, then I can only assume that is what your hearing is for. You wrote in your first post you are going to your AME orthopedic doctor for treatment on a lien. This is confusing as an AME does not treat patients, and is there for examinations. They could recommend treatment previously before Sb 863.

    Your attorney would be the best one to respond to these questions as he knows the specifics to your case and what your hearing is for.

    They should have given you info of an MPN regardless if they have one. The medical unit can look up your employer/IC and find out the MPN if they have one and how to access it. Do a search for their number on the link I provided. This is something you will need IF it is determined your injury is work related, and you wish to switch doctors. If you cannot find another doctor to treat you on a lien, then you will have to wait until the judge decides your injury and THEN you can pick a different doctor within your MPN. You questions are getting confusing as you stated you asked your attorney and employer for your MPN and was not provided it, and I just wrote to you how you can get access via medical unit, and then you state it is irrelevant?

    If your employer has an MPN when/if your case is accepted then you are binded by the MPN, unless your attorney can prove you were not properly notified of the MPN, and that prevented you from receiving medical treatment, and a judge rules that you can. That has to be litigated first. If you treat outside of the MPN once your claim is approved the insurance company has no liability to pay the doctor, or reimburse you. You are assuming by your statement all doctors are bad on the MPN. Wait until you see yours to make that decision. Not all doctors are pill pushers.

    This is a quote on why you need to treat within the MPN if your claim is accepted. You have the option to pay out of pocket to see whomever you want now, since your claim is denied.

    "Additionally, disputes about whether or not an injured worker is subject to an MPN will now have to be resolved as soon as they arise, rather than being held over to the end of a claim. Treatment obtained from a non-network provider, without either authorization from the employer or insurance carrier or a workers' compensation judge's order permitting outside of network treatment, will not have to be paid for by the employer or carrier. If unauthorized treatment is unsuccessful and results in a worsening of the injured worker's condition or a need for additional treatment, the employer/carrier will have no obligation to pay for that, either.
    Last edited by kelly38; 08-19-2013 at 02:30 PM.

  7. #7
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    Default Re: How to Get Worker's Comp Insurance to Authorize Treatment on a Denied Claim

    The current doctor was a AME, i do not know if he was also on the IC's MPN, i have not seen any documents in my file that attest to such.

  8. #8
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    Default Re: How to Get Worker's Comp Insurance to Authorize Treatment on a Denied Claim

    Quote Quoting snowycali View Post
    The current doctor was a AME, i do not know if he was also on the IC's MPN, i have not seen any documents in my file that attest to such.
    I completely understand your frustration with being at a doctor who is doing nothing to help. His hands could be tied as well as the laws changed in our state with liens. It may be more difficult for example to get testing's and other referrals to chiropractor due to the fact they will have to take your case on a lien.

    You have that hearing coming up which you stated will determine if your injury is work related. Try to be patient and wait for that.

    In the mean time if you have another type of insurance or can pay cash you can get treatment that was since your claim has been denied.

    You can ask your attorney this. Since you were never notified of an MPN or how to access it, can he take that issue to the judge and request you be able to treat outside of the MPN (if your claim is deemed work related). Also, some employers do not have a MPN, so you also may not be stuck in one in the first place. Your lawyer may already have a plan about this.

    If you cannot find doctors to treat on a lien and do not have resources to pay for treatment yourself, with a denied claim, I do not see any other thing you can do except wait for your hearing over this issue.

    I wish you the best.

    A good resource you have is you can contact an I&A officer and tell them what is occurring in your claim, and if they can offer some advice.
    Last edited by kelly38; 08-20-2013 at 06:04 AM.

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