California workers’ compensation law requires claims administrators to authorize and pay for medical care that is reasonably required to cure or relieve the effects of the injury. Under laws enacted in 2003 and 2004, this means care that follows scientifically based medical treatment guidelines. It is illegal for a physician or medical facility to bill a worker if they know the injury is or may be work related.
What type of medical care am I entitled to?
You are entitled to reasonable medical treatment to cure or relieve work-related injuries and illnesses. The doctors who treat you must follow treatment guidelines referred to as the medical treatment utilization schedule (MTUS). Only the treatment that meets the guidelines must be approved.
All employers or claims administrators handling their workers’ compensation claims are required by law to have a program called utilization review (UR). This program is used to decide whether or not to approve medical treatment recommended by your doctor.
Can I be treated by my regular doctor?
If you predesignated your personal physician or medical group before you were injured, you can have your regular doctor treat you for your work-related injuries immediately after you are injured.
What if my employer has an MPN?
An MPN is a group of physicians and other health care providers selected by the employer or insurer to treat injured workers. MPNs must be approved by the state Division of Workers' Compensation (DWC). Each MPN includes a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. The claims administrator is required to give you a list of MPN doctors near you. After the first appointment you are free to select another doctor within the MPN.
What if my employer has an HCO?
A health care organization (HCO) is an organization certified by the DWC to provide managed medical care to injured workers. HCOs must have health care providers who understand the workers’ compensation system and occupational health care. If you choose to be in an HCO, the HCO will coordinate all aspects of your medical care for your work injury and work with your employer to get you back to work.
If I haven’t predesignated and my employer doesn’t have an MPN or an HCO, who will be my doctor?
The claims administrator has the right to select your treating doctor for the first 30 days after your employer knows that you were injured. After the first 30 days, you may be treated by a physician of your choice or at a facility of your choice within a reasonable geographic area.
Additionally, if you gave your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to your injury or illness, after 30 days you may be able to transfer care to your personal chiropractor or acupuncturist.
After you have received 24 chiropractic visits, a chiropractor cannot be your personal physician.
What if I have a disagreement about my medical benefits?
At some point during your claim, you or the claims administrator might disagree with what your treating physician reports about your injury or treatment. When there is a disagreement, depending on the type of injury, you may be evaluated by a qualified medical evaluator (QME). To qualify as a QME, a physician must meet additional educational and licensing requirements. They must also pass a test and participate in ongoing education on the workers' compensation evaluation process. If you have an attorney, your attorney and your claims administrator might agree on a doctor to resolve medical disputes. This doctor is called an agreed medical evaluator (AME).
Want to learn more? Find it in the guidebook
Did you know?
- You can contact the Information and Assistance Unit if you have questions about benefits or call 1-800-736-7401 for recorded information
- Medical care must be paid for by your employer if you get hurt on the job — whether or not you miss time from work
- You should never receive a medical bill, as long as you filed a claim form and your physician knows that the injury is work-related
- If you have to travel to get treatment for your work injury, you must fill out the medical mileage expense form for reimbursement of your travel costs. You can find current rates on the benefits chart.
Questions workers have:
- Are there limits on certain kinds of treatment?
- How long can I continue to receive treatment?
- If my doctor’s request for treatment is not approved, what can I do?