For anyone who has suffered a work-related injury or illness, getting quality medical care is a top priority. The doctor who treats you will play a crucial role in the outcome of your workers’ comp case and the benefits you receive. Among other things, your treating physician will:
California has detailed rules about when you can select your first treating physician, as well as when and how you may change doctors. This article explains the basics.
In California, you may be able to go to your personal primary care physician right after you’re injured at work, but only if:
You may also predesignate a qualified medical group. You can use a form provided by the California Department of Workers’ Compensation (DWC Form 9783) to make your predesignation. The rules are somewhat different if your employer or its insurer has contracted with a health care organization (HCO) to provide managed care for work-related injuries and illnesses. When that’s the case, you may predesignate your personal physician, chiropractor, or acupuncturist; your employer must give you the proper predesignation form when you’re hired and once a year after that. (Cal. Labor Code §§ 4600, 4600.3 (2018).)
If you didn’t predesignate your personal doctor, you probably won’t be able to choose the initial physician you see for treatment. When your employer or its insurance company has established a medical provider network (MPN) you’ll generally have to choose a doctor in that network. However, there are some exceptions to this rule, including when:
Similarly, if the insurer has contracted with an HCO, you’ll generally be treated in the HCO immediately after your injury. If there’s no MPN or HCO contract, the claims administrator usually has the right to choose your treating doctor for the first 30 days after your injury. (Cal. Labor Code §§ 4600, 4600.3, 4616.3.)
It’s important that you feel comfortable with your treating physician, both in terms of the care you’re receiving and the decisions the doctor is making about your ability to work. If at any point you strongly disagree with your doctor’s opinions, you may want to switch treating physicians. The process for doing that depends on whether your employer has an MPN or HCO.
If your employer or its insurer hasn’t established an MPN or contracted with an HCO, you may switch to a new treating doctor once during the first 30 days after you reported your injury or illness. However, unless you’ve given your employer the name of your personal chiropractor or acupuncturist before you were hurt, the claims administrator may generally choose the new doctor (if it does so within five days of your request). After 30 days, you may choose your own new treating doctor within a reasonable distance from your home. You can switch doctors again if it’s reasonable. (Cal. Labor Code §§ 4600(c), 4601.)
If your employer has an MPN, you can ask to switch doctors at least twice, but the second and third doctors must be from the MPN. This is true even if you’ve been seeing your predesignated personal physician. If you still disagree with the third doctor’s opinion, you can submit an application for an “independent medical review” with an impartial medical professional. Depending on the outcome of that review, you may then be able to select a doctor outside of the MPN. (Cal. Labor Code §§ 4616.3, 4616.4 (2018).)
If you’ve been seeing a treating doctor within an HCO, you can switch at least once to another doctor within the HCO. You may switch to a new medical provider (including a chiropractor or acupuncturist) after a waiting period: 180 days if you have employer-provided health insurance; 90 days if aren’t covered. The new treating doctor must be within a reasonable distance from your home. The same rules for switching doctors apply if you’ve been seeing your predesignated personal physician, but your employer or insurer has contracted with an HCO. (Cal. Labor Code § 4600.3.)
If you’re having problems with medical issues in your workers' comp case—whether you're not satisfied with the care you've been receiving, you disagree with your doctor’s opinions about your diagnosis or work limitations, or the insurance company is dragging its heels on approving recommended treatment—it would be smart to speak with a workers’ comp lawyer. Attorneys who are experienced in workers’ comp can help you navigate the complicated process of changing doctors and getting approval for needed medical care. They may also be able to recommend good treating doctors who understand the complex workers’ comp system.
And for an in-depth look at how to get good medical care under California’s workers’ comp system, read California Workers’ Comp, by attorney Christopher A. Ball (Nolo).