Medical benefits
| Author | David L. Pollak/Roger A. Tolman, Jr./Monika R. Reyes |
| Pages | 487-546 |
MEDICAL BENEFITS
9-1
CHAPTER 9
MEDICAL BENEFITS
I. PRIMARY DUTY TO PROVIDE MEDICAL TREATMENT
§9:01 General Discussion
§9:02 Defendant’s Affirmative Duty to Provide Treatment
§9:03 Unlimited Reasonable Amount — Limits in Official Medical Fee Schedule
§9:04 “To Cure or Relieve”
§9:05 Mandatory Treatment While Claim Is on Delay
§9:06 Physician Guidelines, MTUS and ACOEM
§9:07 Malpractice Liability
§9:08 Drug Formulary
II. TYPES OF TREATMENTS
A. Statutory Types
§9:10 Nursing, Medicines, Medical Supplies and Apparatus, Physical Therapy, Etc.
§9:11 Licensed “Physicians”
§9:12 Medical Monitoring
§9:13 Medical Devices
§9:14 Medical Rehabilitation Compared With Vocational Rehabilitation
§9:15 Housing Renovations and/or Moving Costs
§9:16 Increased Living Costs
§9:17 Housing in Lieu of Institutionalization
§9:18 Guardian Ad Litem Expenses and Conservatorship Expenses
§9:19 Prescribed Nursing Services and Home Health Care
§9:20 Prescribed Housekeeping Services, Childcare, and Other Miscellaneous In-Home Care
§9:21 Right to Consultation
§9:22 Treatment for Non-Industrial Condition to Treat Industrial Injury — Bolton
§9:23 Treatment for Third Person to “Treat” Industrial Injury
§9:24 Over-the-Counter Medication
§9:25 Hypnotherapy
§9:26 Sperm Donation
§9:27 Chiropractic Care and Physical Therapy
§9:28 Non-FDA Approved Medication
§9:29 Nurse Case Managers
§9:30 Treatment for Deleterious Effects of Ill-Advised Treatment
B. Treatment Through Special Group Plans
§9:41 Treatment by Health Care Organizations (HCO’s)
III. MEDICAL TRANSPORTATION AND LOSTWAGE EXPENSE
§9:50 “Transportation, Meals and Lodging”
§9:51 Statutory Mileage Rule
§9:52 Costs for Employee Examination and Treatment
§9:53 Transportation for Prescriptions — Hutchinson
MEDICAL BENEFITS
California Workers’ Compensation 9-2
§9:54 Lost Wages
§9:55 Interpreter as Part of Treatment?
IV. MEDICAL PROVIDER NETWORKS
§9:56 Establishing MPN and Application of Access Standards
§9:57 Participation in MPN
§9:58 Control of Medical Treatment Within the MPN
§9:59 Independent Medical Review
V. UTILIZATION REVIEW AND THE MTUS
§9:60 MTUS
§9:61 Utilization Review and Sandhagen
§9:61.1 Utilization Review after 01 January 2018
§9:61.2 Resubmission to UR and the 12-Month Rule
§9:62 UR Penalties
§9:63 No Medical/Legal or Judicial Review of UR Denial;
All UR Denials to Be Determined Solely by Independent Medical Review
VI. EMPLOYEE’S “FREE CHOICE” OF PHYSICIAN OUTSIDE OF THE MPN
§9:69 Free Choice of Primary Treating Physician
§9:70 Primary Treating Physician Presumption Eliminated
§9:71 “Reasonable Geographic Area”
§9:72 Free Choice With Prior Designated Personal Physician or Failure to Provide Notice
§9:73 Employer Control for First 30 Days
§9:74 Exercise of Free Choice: 30 Days From “Report” of Injury
§9:75 Employee Duties on Selection
§9:76 Employer Duties on Selection
§9:77 Duties of Employee-Selected Physician
§9:78 Employer Objection to Report(s) of Employee-Selected Physician
§9:79 Sanctions for Non-Compliance
§9:80 Employee’s Right to Change Free Choice Physician
§9:81 Payment Pursuant to Fee Schedule
§9:82 Payment Within 60 Days of Billing or Penalty and Interest
VII. EMPLOYER PETITION FOR CHANGE OF PHYSICIAN: REGAINING EMPLOYER CONTROL
§9:90 Employer Petition to AD
§9:91 Petition for Change Procedures
§9:92 Good Cause Showing
§9:93 Invalid Grounds
§9:94 Answer to Petition
§9:95 AD Disposition of Petition
§9:96 Review of AD Order Granting or Denying Petition for Change
§9:97 Interim Treatment to Be Provided
§9:98 Selection of Proper Forum — AD or WCAB
VIII. RECOVERY OF EXPENSE FOR SELFPROCURED MEDICAL TREATMENT
§9:110 General Obligation
§9:111 Compare “Free Choice” Medical Treatment
§9:112 Notice of Need
§9:113 Waiver of Notice
§9:114 Emergency Treatment or Lack of Employee’s Knowledge of Industrial Nature
§9:115 Ineffective Treatment
§9:116 Relevance of Treatment Success
§9:117 Success/Failure Not Always Relevant
§9:118 If Injury Denied, Physician Reporting Rules Are Generally Inapplicable but the Fee Schedule Still Applies
§9:119 Incidental Expense Recoverable
MEDICAL BENEFITS
9-3 Medical Benefits
IX. MEDICAL FINDINGS AND AWARD
§9:129 Medical Treatment Findings Uncommon in Admitted-Injury Cases
§9:130 Question of Fact
§9:131 Precautionary Awards
§9:132 Award Can (and Sometimes Should) Be Specific as to Modality — Kauffman
§9:133 Apportionment of Medical Award
§9:134 Compare Apportionment of Liability
§9:135 Nature and Extent of Medical Treatment Award
§9:136 Effect of Reopening on Other Issues — Cedillo
§9:137 Termination of Medical Award
§9:138 Credit Against Medical Award?
§9:139 Compare Findings and Awards of Self-Procured Medical Expense
X. UNREASONABLE REFUSAL TO SUBMIT TO MEDICAL TREATMENT OR EXAMINATION
§9:150 Refusal to Undergo Treatment
§9:151 Refusal to Submit to or Cooperate at Examination
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