MEDICAL TREATMENT
1. Can I treat with my own physician for my work injury?
Yes. If you have previously designated in writing to your employer your choice of a treating physician, otherwise the employer may direct you where to treat for the first 30 days after your injury.
2. Can I change my treating physician?
Yes. Labor Code §4600 provides that after 30 days from the date the injury is reported, the employee may be treated by a physician of his or her choice at a facility of his or her own choice within a reasonable geographic area.
The reasonable geographic area, within the context of Labor Code §4600, is determined by giving consideration to the employee’s domicile, place of work, where the injury occurred, the availability of physicians, the employee’s medical history and the employee’s primary language. As a general rule of thumb, if the physician or facility is within 75 miles of your home or work, it is probably within a reasonable geographic area.
In addition, Labor Code §4061 allows the employee one change of physician at any time after a work injury. In the event that you wish to change your treating physician, just complete the “Injured Workers’ Designation of Treating Physician” form and return it to our office. Then call your designated physician and make an appointment for treatment. Let us know if your designated physician needs anything further from our office.
3. Can I obtain a second medical opinion?
Yes. Labor Code §4061 also allows an employee to obtain a second medical opinion in any serious case. If you desire a second medical opinion, please call our office and request a second medical opinion.
4. Is there a limit on the number of chiropractic visits I can obtain?
Yes. For work injuries in 2004 or later, Labor Code §4604.5 limits chiropractic visits to a maximum of 24 per work injury.
5. Is there a limit on the number of physical therapy visits I can obtain?
Yes. For work injuries in 2004 or later, Labor Code §4604.5 limits physical therapy visits to a maximum of 24 per work injury. Use your physical therapy visits wisely. Your course of physical therapy treatment for the duration of your work injury should be discussed with your treating physician and physical therapist. Additional physical therapy visits beyond 24, may be authorized if you have had surgery.
6. Is there a limit on the number of occupational therapy visits I can obtain?
Yes. For work injuries in 2004 or later, Labor Code §4604.5 limits occupational therapy visits to a maximum of 24 per work injury. Additional occupational therapy visits beyond 24, may be authorized if you have had surgery.
7. Is there a limit on the medical treatment I may obtain?
Yes. Under Labor Code §4604.5, the recommended guidelines set forth in the American College of Occupational and Environmental Medical Practice (ACOEM) Guidelines shall be presumptively correct on the issue of extent and scope of medical treatment. These guidelines will be in effect until the Administrative Director adopts a medical treatment utilization schedule.
8. Can you advise me whether to have certain medical treatment?
No. We are not physicians and so we are not qualified to determine whether you should have a medical procedure performed or not. We can only advise you whether your medical treatment will be covered under workers’ compensation or not. In other words, we are only capable of telling you if we will pay for your medical treatment, not whether you should have the medical treatment. Questions pertaining to your course of medical treatment should be discussed with your doctor.
9. Can I be reimbursed for medical treatment that was paid by me?
Yes. If you pay for medical treatment, such as medication prescribed by the doctor, we will reimburse you directly for the reasonable and necessary cost of the prescription. All you need to do is submit a receipt or other proof that you paid for the medical treatment and we will reimburse you. Please make sure that your request for reimbursement is clear that we are to reimburse you and not pay the medical provider. Medical bills and pharmacy prescriptions are reviewed and paid based on a fee schedule as prescribed by the California Labor Code.
In order to avoid having their medical bills reduced per the California fee schedule, some medical providers and pharmacies ask the injured worker to pay for the treatment or prescription out of their own pocket. This results in the medical provider or pharmacy being able to avoid having their bills reduced per the California fee schedule. For example, a pharmacy may charge you $40 for a prescription which should only be charged for $32. If you pay the $40 and request reimbursement from our office, you may only be reimbursed $32.
Please note that after you have filed a “Workers’ Compensation Claim Form” (DWC-1), under §3751(b) of the California Labor Code, it is against the law for the medical provider to collect money directly from you for medical services unless the medical provider has received written notice from us advising that we have denied liability and the provider has sent you a copy of the denial. A medical provider who violates this statute shall be liable for three times the amount unlawfully collected, plus reasonable attorney’s fees and costs. This means a doctor, physical therapist, pharmacy or other medical provider cannot directly collect money from you for their services.
10. Am I reimbursed for my mileage while seeking medical treatment?
Yes. You will be reimbursed for your mileage while seeking medical treatment at the rate of 67 cents per mile in 2024. Enclosed is a form that you may use to request reimbursement of your medical mileage. Please make absolutely sure your mileage is accurate. You may submit your request for mileage reimbursement when you want to be reimbursed.
11. How long does it take for treatment to be authorized?
While the Labor Code allows up to five working days to authorize treatment, most treatment is authorized within one working day. Often the delay in authorization for treatment is because the doctor has not made a written request for treatment as required under the Labor Code. If you are inquiring about the status of treatment authorization with your doctor, make sure you ask your doctor when they requested authorization for treatment from WCA.
12. How long does it take to pay for my medical treatment?
While the Labor Code allows us 60 working days from the date a medical bill is received in our office to pay it, we usually pay much sooner than the 60 working days allowed under the Labor Code.
UTILIZATION REVIEW
1. What is Utilization Review?
Labor Code Section 4610(a) defines Utilization Review (UR) as: “…utilization review or utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians…”.
2. How does utilization review reach a determination regarding the authorization of medical treatment?
Labor Code Sections 4604.5 and 5307.27 state that on or before December 1, 2004, a medical treatment utilization schedule is to be adopted by the State of California. This schedule will incorporate evidence-based, peer-reviewed, nationally recognized standards of care and will address the frequency, duration, intensity, and appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases. Once this schedule is adopted, it will be presumed to be correct on the issue of extent and scope of medical treatment. This presumption is rebuttable and may be controverted by a preponderance of the evidence establishing that a variance from the guidelines is reasonably required to cure and relieve the employee from the effects of his or her injury.
Pursuant to Labor Code Section 4604.5, in the time period between now and when the medical treatment utilization schedule is adopted, the recommended guidelines set forth in the American College of Occupational and Environmental Medical Practice Guidelines (ACOEM) shall be presumptively correct on the issue of extent and scope of medical treatment. This presumption is rebuttable and may be controverted by a preponderance of the evidence establishing that a variance from the guidelines is reasonably required to cure and relieve the employee from the effects of his or her injury.
3. What if I disagree with the determination made by utilization review regarding the authorization of my medical treatment?
If you disagree with the determination made by Utilization Review, you may request an Independent Medical Review (IMR). The request for an IMR must be made within 30 days after services of the Utilization Review determination. Further details on how to proceed with an IMR, including the application, will be included with the Utilization Review determination.
TEMPORARY DISABILITY
1. Do I get money if I cannot work because of my injury?
Yes. If your physician advises us that you are not able to work because of your injury you are entitled to temporary disability (also known as “TD”) during your recovery period. Temporary disability is to compensate you for your lost wages while you are healing.
2. How is my temporary disability calculated?
Determining your weekly temporary disability rate is a two step process. The first step is to determine your average weekly wage (AWW). Your average weekly wage is based on all forms of employment income you receive, including but not limited to, your wages, food, lodging , tips, commissions, overtime, and bonuses for the one year period prior to your date of injury. In some circumstances, like a recent pay raise, your average weekly wage is based on a period less then one year from your date of injury. If you receive a pay raise after your work injury, please let us know in writing.
The second step in determining your weekly temporary disability rate is to multiply your average weekly wage by two and then divide the result by three, subject to a minimum and maximum. The temporary disability minimum and maximum are:
Date of Injury Minimum TD Maximum TD
DOI = 2022 $230.95 $1,539.71
DOI = 2023 $242.86 $1,619.15
DOI = 2024 $242.86 $1,619.15
Your weekly rate for temporary disability is determined by multiplying your average weekly wage by two and then dividing the result by three. Please note that the law has a minimum and maximum average weekly wage for calculating temporary disability.
3. What if I have wages from another job or self-employment?
Since your weekly temporary disability rate is based upon your average weekly wages, if you have worked for another employer or you have been self-employed at any time in the last year, you may be entitled to an increased temporary disability rate. In the event you have worked for another employer or have been self-employed at any time in the last year, please submit proof of your wages or earnings so that we may determine if you are entitled to an increase in your temporary disability rate. If you are temporarily disabled from working at your other job or self employment as a result of your work injury, please submit proof of your lost wages or earnings so that we can determine your temporary disability benefits.
4. When does Temporary Disability start, and how often is it paid?
Temporary disability is not payable for the first three days of disability unless you are hospitalized or you are disabled for more than fourteen days. Temporary disability payments should begin within fourteen days of your employer's knowledge of your work injury and that you are disabled. Your temporary disability check is issued every two weeks on Tuesday.
5. When does Temporary Disability stop?
Temporary disability will stop when you either return to work or the doctor finds that your condition has reached Maximum Medical Improvement (MMI). MMI means that your condition has stabilized and further change is not likely. However, if you are injured on or after April 19, 2004, Labor Code Section 4656(c) limits your temporary disability to a maximum of 104 weeks, unless your injury falls into a specific exception for injuries involving amputations, burns, etc.
6. What if there is an overpayment of my Temporary Disability benefits?
In the event that we overpay your temporary disability benefits we will seek reimbursement of the overpayment or to apply the overpayment against additional benefits you may be entitled to receive.
7. Can I do other activities while receiving Temporary Disability benefits?
When an injured worker is on temporary disability it means they are unable to perform the duties of their job because of the work injury, it does not mean they cannot do any activities. However, if an injured worker is engaged in activities that would indicate they are not temporarily disabled from performing the duties of their job, it may be fraud. For example, if an injured worker sustains a knee injury and while on temporary disability, is surfing, there is certainly going to be a question as to whether the injured worker is truly temporarily disabled. Another example would be a groundskeeper with an injured back who is temporarily disabled from their job with an employer, but continues to do groundskeeper work for their own company.
8. What if I believe I can return to work doing part of my job?
If you believe your work injury restricts you from only part of your job, your employer may be able to temporarily modify your job so that you can return to modified work while you are still recovering from your injury. For example, if on your job you are standing ninety percent of the time and the doctor has placed you on temporary disability because you can only stand forty percent of the time. Then, your employer may be able to temporarily modify your job so that you would only need to stand forty percent of the time.
Whether a temporary modification can be made to your job is really a two step decision. The first step is for the doctor to determine what you are medically precluded from doing because of your work injury. The second step is to determine if your job can be modified to accommodate the temporary work restriction. Your input is valuable in determining how your job could be modified so that you can return to work. If you believe your job can be temporarily modified so that you could return to work, please immediately advise us in writing of the modifications you believe you would need so that you could return to work without risking further injury.
9. What can I do to help facilitate my Temporary Disability benefits?
In most cases, you are the first one to know that your doctor has placed you on temporary disability or that your doctor has released you to return to work. If you are not represented by an attorney, it is extremely helpful if you give us a call when your doctor places you on temporary disability or releases you to return to work. If your doctor gives you a note indicating that you are temporarily disabled or that you are released to return to work, please send this to our office or to your employer.
In addition, if you receive a temporary disability payment that you do not believe you are entitled to receive or you have been paid incorrectly, please immediately notify us, or if you are represented by an attorney, notify your attorney who can then notify us.
10. Is there a statute of limitations on my temporary disability benefits?
If you have been provided with an award of future medical treatment by the Workers’ Compensation Appeals Board and you are temporarily disabled more than five years after your date of injury, no temporary disability will be provided because the statute of limitations will have run unless you have filed a timely Petition to Reopen your claim. The Petition to Reopen must be filed with the Workers’ Compensation Appeals Board within five years from the date of your injury. It is noted that the five year statute of limitations also applies to permanent disability benefits.
PERMANENT DISABILITY
1. What is Permanent Disability?
If your injury or illness results in permanent impairment that reduces your ability to compete in the open labor market you are entitled to Permanent disability (PD).
2. Can I lose my job because I have a Permanent Disability?
Just because you have sustained a permanent disability it does not mean that you cannot perform the duties of your job. For example, you may have a permanent disability work restriction, which prevents you from very heavy lifting, but your job does not require you to do any heavy lifting. In this situation you have a permanent disability but it does not affect your job. If your permanent disability does affect your performing the duties of your job, your employer will determine if they can make a reasonable accommodation of your permanent disability.
3. When is Permanent Disability determined?
Permanent disability cannot be determined until your condition has reached Maximum Medical Improvement (MMI). MMI means your condition has stablizhed and futher change is not likely. Sometimes the term Permanent and Stationary (P&S) is used instead of MMI.
4. Who determines permanent disability?
Permanent disability can be determined by your Treating Doctor, a Qualified Medical Evaluator (QME) or if you are represented by an attorney, by an Agreed Medical Evaluator (AME).
Treating Doctor - In most cases, permanent disability is first addressed by your treating doctor.
Panel QME Doctor - If either you or we disagree with the treating doctor’s assessment of your permanent disability and you are not represented by an attorney, you must be evaluated by a Qualified Medical Evaluator (QME) from a list of three doctors provided by the State Medical Unit (MU). This is commonly referred to as a Panel QME evaluation.
Agreed Medical Evaluator (AME) – If you are represented by an attorney, we may agree with your attorney to have you evaluated by an Agreed Medical Evaluator (AME). If we cannot agree with your attorney on the use of an AME, then your attorney may send you to a Qualified Medical Evaluator and we may send you to a Qualified Medical Evaluator, if you have not previously had a Panel QME evaluation.
Ultimately, if the parties cannot agree to a level of permanent disability, a Judge from the Workers’ Compensation Appeals Board will make the determination of permanent disability.
5. How is Permanent Disability determined?
The description of permanent disability by the doctor is put into a formula to determine your percentage of disability. The percentage of disability equals a specific number of weeks which is then multiplied by your weekly permanent disability rate to arrive at a total dollar amount for your permanent disability. Determining your level of permanent disability is often times difficult, especially if the doctor does not stay within the standard scheduled disabilities contained in the Rating Schedule issued by the State. In fact, rating of permanent disability is so complex, the State has a specific unit, the Disability Evaluation Unit (DEU) that performs the ratings. The Disability Evaluation Unit will issue a Summary Rating Determination (SRD) which will provide their estimate of the permanent disability based upon the medical report they reviewed. Both parties have 30 days to object to the rating.
6. When is Permanent Disability paid?
Once we have knowledge you have sustained a permanent disability, the law requires us to commence payment of permanent disability from your last day of temporary disability or the date your condition becomes permanent and stationary, if you were not temporarily disabled from work.
Permanent disability is paid every two weeks on Tuesday until we have paid the amount of permanent disability we believe you are entitled to receive. In some cases, permanent disability is owed retroactively because there have been several weeks since the last temporary disability was paid or since your condition became permanent and stationary, if you were never temporarily disabled from work. In this case you may receive a lump sum permanent disability advance because the amount is due.
EXCEPTION: Your permanent disability will be paid once the Workers’ Compensation Appeals Board (WCAB) issues an Award, if your employer has offered you a position that pays 85% of your wages at the time of your injury or you have returned to a position that pays you 100% of your wages at the time of your injury.
7. How much permanent disability does workers' compensation pay?
We are required to advance you a reasonable estimate of the permanent disability we believe you are entitled to receive. A reasonable estimate will be based on the medical reports, the nature and extent of medical treatment provided, the duration of your temporary disability and our experience of permanent disability sustained by other similarly situated injured workers.
If you are represented by an attorney, we will withhold up to 15% of the permanent disability for your attorney’s fee. For example, if we believe you are entitled to $1,000 in permanent disability, we will withhold up to $150 for your attorney’s fee. The usual attorney fee is 12% of the permanent disability.
If you, or your attorney if you are represented, disagree with the amount we are advancing for permanent disability, please immediately advise us in writing. You, or your attorney’s cooperation will greatly assist us in avoiding any overpayment of permanent disability in the event our estimate is too high or avoiding a penalty in the event our estimate is too low.
In the event we overpay your permanent disability benefits we will seek reimbursement of the overpayment or to apply the overpayment against additional benefits you may be entitled to receive.
8. At what weekly rate is permanent disability paid?
The weekly permanent disability rate is based upon two thirds of your average weekly wage subject to a minimum and maximum depending on your level of permanent disability and your date of injury. The permanent disability minimum and maximum are:
Date of Injury Minimum PD Maximum PD
DOI = 2022 $160.00 $290.00
DOI = 2023 $160.00 $290.00
DOI = 2024 $160.00 $290.00
9. Do I settle my case if I cash the permanent disability check?
Cashing our check for an advance of your permanent disability is not a settlement of your workers’ compensation claim. The only way to settle a workers’ compensation claim is with approval by a Judge at the Workers’ Compensation Appeals Board.
10. Is there a statute of limitations on my Permanent Disability benefits?
If you have been provided with an award of future medical treatment by the Workers’ Compensation Appeals Board and you believe your level of permanent disability has increased (in other words, you believe your condition has become worse), no additional permanent disability beyond your award will be provided because the statute of limitations will have run unless you have filed a timely Petition to Reopen your claim. The Petition to Reopen must be filed with the Workers’ Compensation Appeals Board within five years from the date of your injury.
MISCELLANEOUS QUESTIONS
1. Is there a statute of limitations on my claim?
Yes. The statute of limitations for your workers’ compensation benefits for this injury, is five years from the date of your injury or one year from the last furnishing of workers’ compensation benefits, whichever is longer.
For example, if you injure yourself today and seek medical treatment and after three weeks the doctor releases you from care without any permanent disability or need for further medical treatment, your file will be closed. If two years from now you need further medical treatment as a result of this injury, your file will be reopened and your medical treatment will be provided. If five years and a day, after your injury, you need medical treatment for your injury and you have not had any medical treatment or other workers’ compensation benefits for this injury in the last year, then you will not be provided with any medical treatment (or any other workers’ compensation benefits) because the statute of limitations will have run unless you have filed an application with, or received an award from, the Workers’ Compensation Appeals Board.
2. What court has jurisdiction over my workers’ compensation claim?
The Workers’ Compensation Appeals Board (WCAB) has exclusive jurisdiction over all workers’ compensation benefits.
3. Do I need an attorney?
The workers’ compensation system is designed to be self executory which means that we are required under the Labor Code to provide an injured worker with the benefits they are entitled to receive, without the injured worker asking for a specific benefit. In other words, if you are entitled to a benefit, we must provide it, even if you do not ask for it.
To ensure that injured workers receive their workers’ compensation benefits, the State of California has created an Audit Unit which comes into our office to review our claim files. The Audit Unit will then assess penalties against our office if benefits have not been provided to the injured worker. It is noted that the last time two times the Audit unit audited our office, we were the least penalized company, of all the companies audited that year.
Of course, it is your choice whether to retain an attorney or not. If you do not have an attorney, the Judge at the Workers’ Compensation Appeals Board “steps into the shoes” of your attorney to ensure that you have received all the workers’ compensation benefits you are entitled to receive.
4. How is a workers’ compensation claim resolved?
Most workers’ compensation claims are closed because the injured worker has fully recovered from their work injury without any need for further medical treatment or sustaining any permanent disability. Some cases are closed because the injured worker does not cooperate with our request that we make upon them to help us determine if they are entitled to workers’ compensation benefits. An example of not cooperating would be not scheduling or attending a medical evaluation, or not returning forms that we request be completed and returned to our office.
In the event that an injured worker sustains a permanent disability and/or the doctor determines that further medical treatment will be needed for the rest of the injured worker’s life, then the workers’ compensation case is resolved with the Workers’ Compensation Appeals Board issuing a Findings and Award. Stipulated Findings and Award or an Order Approving a Compromise and Release.
5. Can I be fired for filing a workers’ compensation claim against my employer?
No. § 132(a) of the California Labor Code clearly states that it is against the law for any employer to discharge, threaten to discharge, or in any manner discriminate against any employee because the employee filed a workers’ compensation claim. If you believe your employer has discriminated against you in violation of Labor Code §132(a), please immediately notify our office in writing of the situation.
6. Is there anything I can do to help secure my benefits?
Absolutely. There are a number of things that an injured worker can do to help secure their workers’ compensation benefits. You can call us and let us know when the doctor has advised you that you are temporarily disabled from work or when the doctor has releases you to return to work. When you write to us, please provide us with your full name and the date of your injury. We realize that workers’ compensation can be quite confusing and if you have questions or concerns, please let us know how we can help you recover from your work injury.
In order to make sure you are receiving all your benefits under workers’ compensation, it is sometimes necessary to obtain medical records from your doctors. To facilitate the receipt of your medical records and providing your workers’ compensation benefits, you will need to date and sign the enclosed “Authorization To Obtain Medical Information” form which is attached.
Please remember that filing a workers’ compensation claim is a serious matter and that Labor Code § 5401.7 states that “any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony”
7. Where can I obtain additional information?
If you would like additional information, you may call the State Division of Workers’ Compensation Information and Assistance Unit at 1 (800) 736-7401 and you will be provided with pre-recorded information. You may also contact Tim Brown at (805) 596-4159 who is the State Information and Assistance Officer for Santa Barbara and San Luis Obispo Counties.
MISCELLANEOUS SITUATIONS
My doctor will not treat me for my work injury.
There is nothing we can do if a doctor will not treat a person for a work related injury.
Why hasn’t my prescription been authorized?
In most cases, if your doctor prescribes a medication for your work injury, a simple call from your pharmacy to our office will result in authorization of the prescription, as long as your doctor has substantiated the prescription in their medical reports to WCA.
Sometimes a pharmacy will tell an injured worker that we have not authorized the prescription when in fact they have not called our office to request authorization. If the pharmacy tells you we have not authorized the prescription make sure you ask the pharmacy if they have called our office yet.
Why did I receive a bill for medical treatment?
If you receive a bill for medical treatment provided for your work injury, it is probably because the medical provider does not have the billing set up as treatment for a work injury or it is a courtesy copy to you. You should send the bill to our office for payment.
Another situation that arises is where we did not pay the full amount requested by the medical provider for their services and the medical provider sends you a balance due bill. The Labor Code requires us to pay all reasonable medical expenses. The medical provider may request us to review their bill again for additional payment or appeal to the Workers’ Compensation Appeals Board.
If we have paid the medical provider a reasonable fee per the Labor Code, the California Court of Appeals has ruled in Bell v. Samaritan Medical Clinic, Inc. (41 CCC 414) that the medical provider cannot bill you for the difference. In addition, under Labor Code §3751(b), providers of medical services are not allowed to collect money for treatment provided to an industrially injured worker unless the medical provider has received written notice that liability for the injury has been rejected by the employer. Any medical provider who violates this subdivision shall be liable for three times the amount unlawfully collected, plus reasonable attorney’s fees and costs.
What happens if my private insurer paid for medical treatment?
Sometimes a medical bill will be paid by your private health insurer for treatment of your work related injury. When this occurs, the private health insurer will send us a request for reimbursement or the medical provider will reimburse the private health insurer and send us a bill for their services. To avoid this situation from arising you should make sure your medical providers know your treatment is for a work injury and to send any bills and reports to our office.
ADDITIONAL INFORMATION
Additional information about workers’ compensation benefits may be obtained at the State of California Division of Workers’ Compensation (DWC) web site located at:
http://www.dir.ca.gov/dwc/dwc_home_page.htm
The DWC web site provides extensive information about workers’ compensation, such as:
- Workers’ Compensation in California: A Guidebook for Injured Workers.
- Fact Sheets – provide information about specific benefits and procedures.
- Injured Worker Guides – detailed instructions on how to complete forms.
- Forms – you may need some of these forms during your claim.
In addition to the web site, the DWC has Information and Assistance (I&A) Officers can be reached at:
San Luis Obispo, CA (805) 596-4159
For recorded information from the DWC and a list of their offices, you may call (800) 736-7401.
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