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.

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 —  on the date of injury — he or she has health care coverage for non-occupational injuries or illnesses. A predesignated personal physician must be a medical doctor (M.D.), doctor of osteopathic medicine (D.O.), or an integrated multi-specialty medical group; must have treated the worker in the past; must retain the worker’s medical records, and must have agreed to provide workers’ compensation medical care to the worker prior to the industrial injury.

The duration of employer medical control varies with the medical delivery model:

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 from which to choose.

If the employer or the employer’s insurer does not have an MPN, the injured worker may be able to change their treating physician to their personal chiropractor or acupuncturist following a work-related injury or illness. This must be a chiropractor or acupuncturist who treated the injured worker in the past, retains their medical records, and who has agreed to treat the patient for workers’ compensation injuries or illnesses prior to their industrial injury. In order to be eligible to make this change, the employee must have given their employer the name and business address of their personal chiropractor or acupuncturist, in writing, prior to the injury or illness. After the claims administrator has initiated treatment with another doctor during the period of the employer’s medical control, the injured worker may then — upon request — have their treatment transferred to their personal chiropractor or acupuncturist.

NOTE: If the date of injury is January 1, 2004 or later, use of a chiropractor as a treating physician is subject to the cap of 24 visits for chiropractic care, so visits beyond that must be authorized in writing by the employer.

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 days of receipt and pay properly documented bills within 45 days (within 60 days for a government employee). Claims administrators have 60 calendar days to pay or object to medical-legal bills. Uncontested medical service bills submitted electronically, however, shall be paid within 15 working days after electronic receipt of the billing.

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 communicate necessary information to claims administrators:

• Doctor’s First Report of Occupational Injury or Illness (Form 5021). This form must be submitted by each physician within five (5) days of initial treatment.

Note on First Aid: Labor Code section 6409 requires that a Doctor’s First Report be submitted to the claims administrator for every work injury or illness, even for “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 “[a]ny 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.”

A Primary Treating Physician submitting a narrative report should follow the requirements in CCR 10606 (http://www.dir.ca.gov/t8/10606.html).

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 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 (for injuries on or after January 1, 2005) http://www.dir.ca.gov/dwc/PR-4.pdf.pdf.*

* For dates of injury on or after 1/1/13, the first physician who finds that disability from all conditions for which compensation is claimed has become permanent and stationary (or reached maximum medical improvement), and the injury has caused permanent partial disability, is required to complete DWC-AD form 10133.36, Physician’s Return-to-Work and Voucher Report, available here: http://www.dir.ca.gov/dwc/forms/SJDB/10133.36.pdf

California workers’ compensation medical services are subject to preauthorization of non-emergency services. Unless agreed to by a claims administrator under CCR  9792.9.1(c)(2), a request for authorization must be set forth on a “Request for Authorization (DWC Form RFA),” completed by a treating physician, as contained in CCR 9785.5, and available here: http://www.dir.ca.gov/dwc/DWCPropRegs/IMR/IMRFormRFAClean.pdf

The RFA must be signed by the treating physician. A “completed” RFA, as defined in CCR 9792.6.1(t), is one that identifies both the employee and provider, identifies with specificity recommended treatment(s), and is accompanied by documentation substantiating the need for the requested treatment.

Claims administrators must respond to requests for payment authorization of medical goods and services within five business days of receipt of the written request for prospective or concurrent authorization and any necessary supporting documentation (CCR 9792.9.1). 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 treatment to be consistent with the Medical Treatment Utilization Schedule (MTUS). The Division of Workers’ Compensation (DWC) provides education to physicians on the Medical Treatment Utilization Schedule (MTUS) and utilization review/independent medical review (UR/IMR), which may be accessed here: https://www.dir.ca.gov/dwc/CaliforniaDWCCME.htm

Utilization review (UR) of an RFA may be deferred if the claims administrator disputes liability for either the occupational injury for which treatment is being recommended, or the recommended treatment itself on grounds other than medical necessity. (CCR 9792.9.1(b)).

Note: a UR decision to modify, delay or deny a treatment request shall remain effective for 12 months from the date of the decision without further action by the claims administrator (with regard to any further recommendation by the same physician for the same treatment), unless the further recommendation is supported by a documented change in the facts material to the basis for the UR decision. (CCR 9792.9.1(h)).

If the request for authorization of medical treatment is not approved, or is approved only in part, any dispute shall be resolved in accordance with Labor Code sections 4610.5 and 4610.6. Neither the employee nor the claims administrator shall have any liability for medical treatment furnished without the authorization of the claims administrator if the treatment is delayed, modified, or denied by a utilization review (UR) decision unless that UR decision is overturned by independent medical review (IMR) or the Workers’ Compensation Appeals Board (WCAB).

Effective 1/1/18, certain treatment for a compensable claim and body part (if rendered by certain physicians during the 30 days after the initial date of injury) will not be subject to prospective UR. See Labor Code section 4610, operative January 1, 2018, for details.

California has adopted a Drug Formulary as part of the MTUS, details of which may be found in CCR 9792.27.1 et. seq. If an injured worker is continuing to receive drug treatment that began prior to 1/1/18, and that treatment includes one or more drugs not listed as Exempt on the Formulary, the prescribing physician must submit a new RFA and progress report prior to 4/1/18 that either:

• transitions the injured worker to an Exempt drug treatment pursuant to MTUS (including weaning or tapering), or
• provides documentation supporting the medical necessity for continuing drug treatment that is not listed as Exempt.

The Official Medical Fee Schedule (OMFS) sets maximum reasonable fees for medical services provided to injured employees. The OMFS fee schedule is available online at the DWC website http://www.dir.ca.gov/dwc/OMFS9904.htm

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.