P H Y S I C I A N S
Who can treat injured workers?
Under California law, initial treatment of workers with job related injuries or illnesses is rendered by an employer-selected physician unless the employee properly predesignated a "personal physician" in writing prior to the injury and his or her employer provides group health insurance. Employer medical control varies with the medical delivery model:
| Traditional: || 30 days |
| Health Care Organization (HCO): || 90 or 180 days |
| Medical Provider Network (MPN): || Life of the claim |
| Predesignated Physician: || 0 days |
An employee under the traditional model who wants to change physicians prior to the expiration of employer medical control may do so by notifying the claims administrator, who will provide a list of doctors to choose from.
Medical treatment should be directed exclusively by a physician, a term that includes medical or osteopathic doctors, podiatrists, chiropractic practitioners, dentists, optometrists, acupuncturists and psychologists providing services within their scope of practice.
What reports must I submit?
Timely reports are necessary to determine the injured worker's right to compensation and the payment and duration of benefits. Any delay in reporting by the physician may result in delayed payment to the injured worker. Likewise, timely reporting is important in the medical billing process. Under Labor Code Section 4603.2, a claims administrator must object to a medical treatment bill within 30 working days of receipt and pay properly documented bills within 45 working days (within 60 working days for a government employee). Claims administrators have 60 calendar days to pay or object to medical-legal bills. If a physician submits incorrect or incomplete information, however, the claims administrator may delay payment. The state requires physicians to provide the following reports in the specified formats to channel necessary information to claims administrators.
• The Doctor's First Report of Occupational Injury or Illness (Form 5021) must be submitted by each physician within five (5) days of initial treatment. (Note on First Aid: Labor Code Section 6409 requires a Doctors First Report be submitted to the claim administrator for every work injury or illness, even "first aid" cases where there is no lost time from work and where neither an Employer's Report (Form 5020) nor an Employee Claim Form (DWC-1) are required. Labor Code Section 5401 defines first aid as "Any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care.")
Click here to download Doctor's First Report for printing
• Treating Physician Progress Report. Unless good cause is shown, a primary treating physician shall sign and transmit a report to the claims administrator within 20 days of an examination when any one or more of the following triggering events occurs:
1. The employee's condition undergoes a previously unexpected significant change;
2. There is any significant change in the treatment plan reported, including but not limited to, (A) an extension of duration or frequency of treatment, (B) a new need for hospitalization or surgery, (C) a new need for referral to or consultation by another physician, (D) a change in methods of treatment or in required physical medicine services, or (E) a need for rental or purchase of durable medical equipment or orthotic devices;
3. The employee's condition permits return to modified or regular work;
4. The employee's condition requires him or her to leave work, or requires changes in work restrictions or modifications;
5. The employee is released from care;
6. The primary treating physician concludes that the employee's permanent disability precludes, or is likely to preclude, the employee from engaging in the employee's usual occupation or the occupation in which the employee was engaged at the time of the injury, as required pursuant to Labor Code Section 4636(b);
7. The claims administrator reasonably requests appropriate additional information that is necessary to administer the claim. "Necessary" information is that which directly affects the provision of compensation benefits as defined in Labor Code Section 3207.
When a physician provides continuing medical treatment, a progress report shall be made no later than 45 days from the last report of any type, even if no triggering event described in paragraph (1) to (7) has occurred. Click here to obtain a Primary Treating Physician's Progress Report (PR-2 Form).
• Special Reports. The claims administrator may request a specialist physician to provide a consultation or second opinion, or a special report of unusual information.
• Final Reports. When a primary treating physician determines that an employee's condition is permanent and stationary, within 20 days from the date of the examination the physician shall, unless good cause is shown, report any findings on the existence and extent of permanent impairment and limitations, apportionment to previous injuries or preexisting conditions and any need for continuing and/or future medical care. This information may be submitted on the "Primary Treating Physician's Permanent and Stationary Report" (PR-3 form for pre-2005 injuries http://www.dir.ca.gov/dwc/PR-3.pdf or the PR-4 form http://www.dir.ca.gov/dwc/PR-4.pdf.pdf for injuries on or after January 1, 2005).
A Primary Treating Physician submitting a narrative report should follow the requirements in CCR 10606 (http://www.dir.ca.gov/t8/10606.html).
Do I need to get authorization for treatment?
A request for authorization is a request for a specific course of proposed medical treatment set forth on the Doctor's First Report Form 5021 or in the Primary Treating Physician's Progress Report.
Claims administrators must respond to requests for payment authorization of medical goods and services within five working days of receipt of the written request for prospective or concurrent authorization and any necessary supporting documentation (CCR Section 9792.9). For retrospective requests, claims administrators are allowed 30 days to respond. If the patient's condition warrants an expedited response, it is due within 72 hours of the written request. State law requires medical payment authorizations to be consistent with the Medical Treatment Utilization Schedule (MTUS).
How do I bill and get paid?
The Official Medical Fee Schedule (OMFS) sets maximum reasonable fees for medical services provided to injured employees. Copies of the 1999 Official Medical Fee Schedule may be purchased from the State of California, State and Consumer Services Agency, Legislative Bill Room. To order the 1999 OMFS, please see attached order form click here or call the Legislative Bill Room at (916) 445-2645.
Click here for general instructions and a summary of effective dates for various fee schedules.
Medical billings should be sent directly to the claims administrator or the claims administrator's designated agent, along with documentation to support the services/goods that are billed. Patients may not be billed for medical services if the health care provider is aware that a workers' compensation claim has been filed and the claim is pending. Unless the medical provider has received written notice that liability for the injury has been rejected and has provided a copy of this notice to the employee, a provider who collects money directly from an injured worker for services to cure or relieve the effects of an injury for which a claim is accepted or pending is liable for three times the amount unlawfully collected, plus reasonable attorney's fees and costs.