Key Takeaways:
- California Workers’ Compensation generally covers reasonable medical treatment needed for a work-related injury.
- Treatment or payment may be delayed because of authorization issues, Medical Provider Network (MPN) rules, utilization review, or disputes over whether an injury is work-related.
- Dental and specialist care may be covered when medically necessary for a compensable injury.
- Different procedures apply depending on whether the dispute involves treatment authorization, an MPN, claim denial, or an unpaid provider bill.
If you are dealing with Workers’ Compensation not paying your medical bills, you may still have options for getting treatment approved or resolving the disputed charges. California Workers’ Compensation generally requires the claims administrator to pay for reasonable medical care needed to cure or relieve the effects of a covered workplace injury, and the correct response to a denial depends on why the insurer has delayed or denied your payment.
Why Workers’ Compensation Denies or Delays Medical Bills
Medical treatment can be delayed for several reasons. A claims administrator may dispute whether the injury is work-related, question whether a requested treatment is medically necessary, or require additional documentation from the treating physician.
Common issues include the following:
- A “Request for Authorization” was not properly submitted.
- Utilization review modified or denied the requested treatment.
- The insurer disputes that the injury is covered.
- Treatment was obtained outside an applicable MPN.
- The provider and claims administrator disagree about payment.
If treatment has already been provided, an unpaid bill does not automatically mean the injured worker must pay it. Under state law, medical providers generally may not bill an injured worker when they know the condition is or may be work-related.
Understanding the Medical Provider Network (MPN)
An MPN Workers’ Compensation network is “a group of health care providers approved to treat employees with workplace injuries.” Employers and insurance carriers may require injured workers to receive treatment through an approved MPN unless an exception applies.
After the initial medical evaluation, an injured worker can generally select another physician within the network. California also provides procedures for second and third opinions when a worker disagrees with a treating physician’s diagnosis or treatment.
If you are unable to find an appropriate provider, document the doctors you contacted, appointment availability, referrals, and communications with the claims administrator.
Dental and Specialist Care Under Workers’ Compensation
- Can Workers’ Compensation Cover a Dentist?
A Workers’ Compensation dentist may be available when dental treatment is medically necessary because of a covered workplace injury. For example, a workplace accident could cause injuries to the teeth, jaw, or mouth.
- What if the MPN Does Not Have the Specialist You Need?
MPNs must meet state requirements concerning provider access. If the network cannot provide appropriate treatment within applicable requirements, additional options may become available. Keep written records of any unsuccessful attempts to obtain care.
How a Lawyer Forces the Insurer to Pay
A lawyer can use California’s Workers’ Compensation procedures to challenge improper treatment delays or denials. They can also identify the type of dispute, monitor filing deadlines, gather medical documentation, communicate with the insurer, and pursue the appropriate Workers’ Compensation procedure.
Frequently Asked Questions (FAQs):
Do I have to pay medical bills if Workers’ Compensation refuses to pay?
Not necessarily. California rules restrict providers from billing injured workers for treatment they know may be related to a Workers’ Compensation claim.
What is an MPN in Workers’ Compensation?
An MPN is an approved network of medical providers used to treat employees with occupational injuries.
Can Workers’ Compensation pay for dental care?
Yes, when dental treatment is medically necessary because of a covered workplace injury and applicable Workers’ Compensation requirements are satisfied.
What can I do if Workers’ Compensation denies treatment?
Your options depend on the reason for denial. Possible procedures include Independent Medical Review, an expedited hearing, or challenging a denial of the underlying claim.
Can I change doctors within an MPN?
Generally, injured workers may select another physician within the MPN after the initial medical evaluation, subject to California Workers’ Compensation rules.
Our Experienced Sacramento Workers’ Compensation Lawyers at Walters & Zinn, Attorneys at Law Can Evaluate Your Claim
If unpaid or delayed medical treatment is interfering with your recovery, our Sacramento Workers’ Compensation lawyers at Walters & Zinn, Attorneys at Law, can evaluate the dispute and protect your rights. To schedule a free consultation, call us today at 916-610-4706 or submit our online contact form. With office locations in Folsom and Fairfield, California, we proudly serve clients in the surrounding areas.