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Medical Care

Workers’ Compensation Attorney in Sacramento

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The FAQ information on this page is from the Department of Industrial Relations website.

Medical Care

What kind of medical care will I receive for my injury?
Doctors in California’s workers’ compensation system are required to provide evidence-based medical treatment. That means they must choose treatments scientifically proven to cure or relieve work-related injuries and illnesses. Those treatments are laid out in a set of guidelines that provide details on which treatments are effective for certain injuries, as well as how often the treatment should be given (frequency), the extent of the treatment (intensity), and for how long (duration), among other things.

To comply with the evidence-based medical treatment requirement, the state of California has adopted a medical treatment utilization schedule (MTUS). The MTUS includes specific body regions guidelines adopted from the American College of Occupational and Environmental Medicine’s (ACOEM) Practice Guidelines, plus guidelines for acupuncture, chronic pain and therapy after surgery. The DWC has a committee that continuously evaluates new medical evidence about treatments and incorporates that evidence into its guidelines.

Do these guidelines apply if my case is already settled?
They may. Treatment guidelines are considered correct even in cases that settled before the guidelines were added to workers’ compensation law in 2003. Your claims administrator may continue to pay for medical care you’re accustomed to for your injury. If you have a question about whether you should still be receiving a certain kind of medical treatment and you can’t work it out with your claims administrator, call your local information & assistance officer for guidance.

If your medical treatment has been denied you can request an expedited hearing before a workers’ compensation administrative law judge to get the situation resolved. Contact the information & assistance officer at your local DWC district office for help.

The claims administrator hasn't accepted or denied my claim yet, but I need medical care for my injury now. What can I do?
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.
Are there limits on certain kinds of treatment?
Yes. If your date of injury is in 2004 or later, you are limited to a total of 24 chiropractic visits, 24 physical therapy visits, and 24 occupational therapy visits, unless the claims administrator authorizes additional visits or you have recently had surgery and need postsurgical physical medicine.
How long can I continue to receive treatment?
For as long as it’s medically necessary. However, some treatments are limited by law and the medical treatment you receive must be evidence-based.

The MTUS lays out treatments scientifically proven to cure or relieve work-related injuries and illnesses. It also deals with how often the treatment is given and for how long, among other things.

If the treatment your doctor wants to provide goes beyond what is recommended by the MTUS, your doctor must use other evidence to show the treatment is necessary and will be effective.

Additionally, your doctor’s treatment plan may be reviewed by a third party hired by the claims administrator. This process is called utilization review (UR). All claims administrators are required by law to have a UR program. They use UR to decide whether or not to approve treatment recommended by your doctor.

What is utilization review?
UR is the program claims administrators use to make sure the treatment you receive is medically necessary. All claims administrators are required by law to have a utilization review program. This program will be used to decide whether or not to approve medical treatment recommended by your doctor.

The state has rules about how UR must be conducted. If you believe the UR company reviewing your doctor’s plan is not following those rules you can file a complaint with the DWC.

Find more information about utilization review in the factsheet.

If my doctor's request for treatment is not approved, what can I do?
There are specific timelines you must meet or you will lose important rights. As of July 1, 2013, medical treatment disputes for all dates of injury will be resolved by physicians through the process of independent medical review (IMR). If UR denies or modifies a treating physician’s request for medical treatment because the treatment is not medically necessary, you can ask for a review of that decision through IMR.

Along with the written determination letter that denied or modified your requested treatment, you will receive an unsigned but completed IMR form and addressed envelope. If you disagree with the decision, you must sign and send this form in the envelope to start the IMR process.

Please visit the IMR FAQ at http://www.dir.ca.gov/dwc/IMR/IMR_FAQs.htm for detailed information about the process itself, eligibility and deadlines, as well as a link to the IMR request form.

What happens if I was treated and the claims administrator won't pay for it? Do I have to pay?
You most likely will not have to pay. This is a problem your doctor and the claims administrator need to work out.
What is a medical provider network?

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.

What is a health care organization?

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

What is a primary treating physician (PTP)?
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).
What does predesignating a personal doctor involve?

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.

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

Does the 24 visit cap on chiropractic visits apply to all cases?
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.
What if I disagree with the MPN doctor's treatment plan?
If you disagree with your MPN doctor about your treatment, you can change to another physician on the MPN list. You can also ask for a 2nd and 3rd opinion from different MPN doctors. If you still disagree, you can have an IMR to resolve the dispute. See the information on your MPN provided by your employer.
What if I disagree with the MPN doctor's opinion regarding my ability to return to work, whether I'm permanently disabled, or if I need future medical treatment?
If you disagree with your MPN doctor on any issues other than diagnosis or treatment, you must request a qualified medical examiner (QME).
What if the MPN doctor's request for treatment is denied by UR or the claims administrator?
Along with the written determination letter that denied or modified your requested treatment, you will receive an unsigned but completed IMR form and addressed envelope. If you disagree with the decision, you must sign and send this form in the envelope to start the IMR process.< Please visit the IMR FAQ at for detailed information about the process itself, eligibility and deadlines, as well as a link to the IMR request form.
Who decides what type of work I can do while recovering?

Your treating doctor is responsible for explaining in a medical report:

  • The kind of work you can and can’t do while recovering
  • The changes needed in your work schedule or assignments.
  • You, your treating doctor, your employer and your attorney (if you have one) should review your job description and discuss the changes needed in your job. For example, your employer might give you a reduced work schedule or have you spend less time on certain tasks.

If you disagree with your treating doctor, you must promptly write to the claims administrator about the disagreement or you may lose important rights.

I don't have an attorney and I have a disagreement about what my doctor report says about my injury. What should I do?

You may request a medical evaluation with a physician called a qualified medical evaluator or QME:

  • If your claim is delayed or denied and you need a medical evaluation to find out if the claim is payable
  • To find out if you are permanently disabled in some way or if you’ll need future medical treatment
  • If you disagree with what your treating physician says about your injury, work restrictions, or TD status. However, a QME may not comment on a request for medical treatment. If your doctor’s treatment request is denied and you disagree with the UR decision, you may request an IMR

If you are represented, your attorney and the claims administrator may agree on a doctor to examine you. To receive a list of QMEs to choose from, complete the panel request form(QME 105) and mail it to the DWC Medical Unit. Ask your treating physician to help if you don’t know what kind of doctor should look at your injury.

Within 20 working days of the request, the DWC Medical Unit will send a list (also called a panel) of three QMEs to you and the insurance company. QME lists are randomly selected and do not represent your employer or the insurance company.

You have 10 days from the date the list is printed and mailed to select a QME from the list, make an appointment and tell the insurance company which doctor you picked and the date of your appointment. If you don’t do this within 10 days, the insurance company will have the right to pick the doctor you’ll see and make the appointment.

What if the claims administrator has sent me a QME panel request form?
You might need to see a QME if the insurance company disagrees with something in your claim. In that case, the insurance company will give you the form to request a QME. When this happens, you have 10 days to request a QME list by sending the form to the DWC Medical Unit. If you don’t send the form within 10 days of receiving it, the insurance company will have the right to request the QME list and select the kind of doctor you’ll see.

Within 20 working days of the request, the DWC Medical Unit will send a list (also called a panel) of three QMEs to you and the insurance company. QME lists are randomly selected and do not represent your employer or the insurance company.

You have 10 days from the date the list is printed and mailed to select a QME from the list, make an appointment and tell the insurance company which doctor you picked, and the date of your appointment. If you don’t do this within 10 days, the insurance company will have the right to pick the doctor you’ll see and make the appointment.

What qualifications do QMEs have?

The DWC Medical Unit certifies QMEs in different medical specialties. A QME must be a physician licensed to practice in California. QMEs can be medical doctors, doctors of osteopathy, chiropractors, psychologists, dentists, optometrists, podiatrists or acupuncturists.

What's the difference between a QME and an AME?
If you have an attorney, your attorney and the claims administrator may agree on a doctor without using the state system for getting a QME. The doctor they agree on is called an agreed medical evaluator (AME). If they cannot agree, they must ask for a QME panel list.
I don't get the QME process. Why do I need to see a QME?

You and/or the claims administrator might disagree with what the treating doctor says. There could be other disagreements over medical issues in your claim. A doctor has to address those disagreements. You might disagree over:

  • Whether or not your injury was caused by your work
  • Whether or not you may need future treatment for your injury
  • Whether or not you need to stay home from work to recover
  • A permanent disability rating.

The QME (or AME if you’re represented by an attorney) report will help determine what benefits you receive.

Is there anything I can do if I disagree with what the QME says?
Yes, but you have a limited amount of time to decide if you agree with the QME’s report or if you need more information. When you receive the report, read it right away and decide if you think it is accurate. If not, and you have an attorney, you should talk to him or her about your options.

If you don’t have an attorney, and you believe there are factual errors in the QME’s report, you can request factual correction of the report by making a request within 30 days of receipt of the report.

The claims administrator may also request factual correction of the report.

Upon receipt of a request for factual correction of the report, the QME is required to file a supplemental report with the DEU and state whether factual correction is necessary to ensure accuracy of the report and, if so, whether the factual corrections change the opinions of the QME stated in the comprehensive medical report.

More information may be obtained from the I&A officer at your local DWC district office.

If you are in a union, you may be able to see an ombudsperson or mediator under the terms of your collective bargaining agreement or labor-management agreement.

Find more information about QMEs and AMEs in the  factsheet.

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