Controlling Your Medical Treatment: Is Pre-designation the Right Option for You?
The landscape of access to medical treatment for injured workers, particularly control of medical treatment, has changed drastically in the last 15 years.
Pre-designation from a Historical Perspective
Legislative amendments to Labor Code (LC) Section 4600, effective on January 1, 1976, narrowed an employer's control to designate a treating physician to the first 30 days following the report of the worker's industrial injury. The injured worker was able to select the physician with whom he or she wanted to treat after the 30-day period. The sole exception being an employer's showing of good cause via a Petition to the Workers' Compensation Appeals Board as to why the employer should have medical control.
With the passage of Senate Bill (SB) 899 in 2004, the pendulum swung back in favor of employers. Changes included the implementation of Medical Provider Networks (MPNs). Aside from four exceptions delineated in the Labor Code, an injured worker was required to treat within the employer's MPN as long as the injured worker received notice of his or her rights concerning the MPN. A new wave of changes came in 2012 with the passage of SB 863, which made it increasingly difficult for an injured worker to obtain treatment outside of the employer's MPN.
Despite the changes that followed SB 899 and SB 863, pre-designation survived. Under LC 4600 and 4601, an employee who followed the appropriate steps in pre-designating a personal physician prior to an industrial injury was permitted to treat outside the MPN with that pre-designated physician.
Pre-designation When the Employer Has an MPN
Under LC 4600(d), an employee who properly pre-designates a personal physician can treat with that physician despite an employer's properly established MPN. When there is a properly established MPN, every new employee must be provided notice of the requirements to pre-designate as well as a pre-designation form when hired or prior to the end of the first pay period. In order to even be eligible to pre-designate, an employee must have health insurance to cover non-industrial injuries. If not, pre-designation will not be permitted.
Certain requirements must be met in order to properly pre-designate a personal physician under LC 4600(d).
- The employer must be notified of the pre-designation prior to the industrial injury.
- A "personal physician" may be either a person or a medical group, subject to certain requirements. A personal physician must be licensed under the Business and Professions Code. As chiropractors, psychologists and acupuncturists are not so licensed they may not act as a personal physician for purposes of pre-designation.
- A personal physician must have acted as the injured worker's primary care physician, treated the injured worker prior to pre-designation and agree to retain the injured worker's medical records.
- The personal physician must agree to the pre-designation. It is important to note that unless you consent to such communication, the employer cannot contact the pre-designated physician prior to the start of treatment either to confirm the pre-designation or to obtain your medical history.
Once you have properly pre-designated a physician, it is the employer's responsibility to provide authorization for the physician to treat, inform the physician of billing information, provide records pertaining to any prior treatment of the industrial injury, as well as where to fax treatment authorization requests. However, when it comes to the appropriate forms the personal physician is to use, the only requirement is that the employer directs the physician to the Division of Workers' Compensation website.
Pre-designation When the Employer Does Not Have an MPN
LC 4601 pertains to pre-designation when the employer does not have a properly established MPN. In such a case, the employer can exercise medical control for the first 30 days following the date of injury. Notice of the ability to pre-designate must be provided to every new employee at the time of hire or by the end of the first pay period.
The injured worker can request a change of treating physician 30 days after reporting the injury. In addition, an injured worker can treat with a personal chiropractor or personal acupuncturist as long as the injured worker has advised the employer in writing prior to the industrial injury. Similar to the requirements of a personal physician, such professionals must be licensed, have an established relationship with the injured worker and agree to retain the injured worker's treatment records.
To designate a personal chiropractor or personal acupuncturist, complete the appropriate form found at the Department of Industrial Relations website. The same responsibilities outlined above concerning a properly designated a personal physician apply. It is important to note, however, that should you elect to pre-designate a personal chiropractor and your injury occurred on or after January 1, 2004, you will be limited to 24 visits. Additional visits are discretionary and must be authorized in writing by the employer.
Pre-designation When the Employer Has Opted for a Health Care Organization
Some employers opt for a Health Care Organization (HCO), which contracts with an employer to provide medical care. If your employer has an HCO in which you are enrolled, the employer will have medical control for the first 90 or 180 days depending on the services the HCO provides. If your employer does not provide non-occupational health care, the period of control is limited to 90 days from the date you report the injury. If your employer does provide non-occupational healthcare, the period of control is extended to 180 days.
If you elect not to enroll in the employer's HCO you may designate a personal physician, chiropractor or acupuncturist. Every new employee must be given the option to enroll in the HCO or designate a personal physician, chiropractor or acupuncturist 30 days following the date of hire. For current employees, the option to designate or enroll must be provided no later than 30 days prior to the conclusion of the enrollment period.
Regardless of whether you pre-designate under LC 4600, LC 4601 or an HCO, all medical treatment and services within California's workers' compensation system are subject to pre-authorization, with the exception of emergency services and treatment. A request for authorization must be set forth on a Request for Authorization Form, and be completed by the personal physician, chiropractor or acupuncturist.
Two Sides to the Pre-designation Story
It is advantageous having a physician treat you who is familiar with your medical history, and can tailor a more individualized treatment plan to expedite your recovery. However, this familiarity could very easily become a disadvantage because the designated doctor must abide by the same laws and regulations when requesting treatment as those providers within the MPN. Failure to do so can lead to treatment delays or denials. So, it is wise to ask your pre-designated physician if she or he is willing to abide by the laws and regulations when requesting treatment. If your pre-designated personal physician is unwilling or unable to do so, the fact that he or she is pre-designated will be of little use as the treatment will likely be denied.
If you are interested in pre-designating a personal physician to act as your primary treating physician in the event of a work place injury, complete the pre-designation form with your selected provider, return it to your human resources or benefits department representative for processing, and keep a copy for your records.
If you have any questions or concerns about the medical treatment process in a workers' compensation case, call us at 213-739-7000 or click here.