Being injured on the job in California can not only cause physical issues, but it can be an emotional and financial rollercoaster. Medical expenses and lost wages is something workers’ compensation benefits is expected to cover. However, being approved for the benefits can be a trying experience. If the process has sticking points with the Division of Workers’ Compensation, or the employer or insurer seeks to deny the claim, it is important to understand legal options.
Fortunately, research indicates that a high rate of injured workers get approved for treatment through workers’ compensation. According to the study, changes made by the state to smooth the process of medical review and approval have resulted in more than 94% of cases being approved, or approved after modifications were made. The study was conducted by the California Workers’ Compensation Institute. It assessed various aspects of the process for 10 months after the changes in 2018 to the Utilization Review and Independent Medical Review.
The changes included evidence for prescription drugs and their exemption, UR exemptions if the injured worker received medical services within 30 days of the injury, emergency care and basic services adhering to evidentiary guidelines. For 29% who had a UR denial that was sent for IMR, there was an overturn in 8.5% of the cases. The final approval depended on the category in which the injured worker was placed and ranged from 78.6% to 99.7%.
Those needing prescriptions were successful 88.1% of the time during UR. Modifications occurred in 2.6%. More than 9% had a denial. IMR overturned 10.6% of the denials. There was a low rate of less than 3% denial for those needing anti-inflammatory medication. Higher rates of denial were for those who needed opioids, at 17.4%, dermatological medications, at 18% and musculoskeletal agents, at nearly 21%.
While people who are injured on the job and need workers’ compensation would prefer to think about how they can get the proper medical care, medications and payment for lost wages, it is important to understand the likelihood of an approval and reasons for which there might be a denial during UR and the chance of it being overturned during IMR. Rather than make the situation worse with fear about the process of getting workers’ compensation, getting the right information can allow the worker to focus on getting better.