If your San Diego work comp claim is accepted by the insurance adjuster, then you have the right to select a doctor to be your Primary Treating Physician (PTP). In San Diego, the insurance company will have a network of doctors called a Medical Provider Network (MPN), and if so, you must choose your PTP from this network which is located in the San Diego Work Comp Appeals board building (second floor). If the work comp insurance claims examiner happens to dislike the doctor that you selected, you may be referred to a Qualified Medical Examiner (QME) for a second medical opinion on behalf of the work comp insurance company, or you may be offered an Agreed Medical Examiner (AME). You really should have legal counsel at this point to go over your options for your specific work injury case.
But Wait, It Does Not Stop Here:
However, the San Diego workers' compensation legal and medical battle does not stop there, selecting the correct PTP is only half of the battle in terms of getting the necessary medical care. More specifically, once you have selected your medical doctor for your injury case, and the medical doctor recommends an appropriate course and scope of medical treatment for you, the work comp insurance company then has the right to submit these recommendations for an outside review before they agree to pay for the treatment. Remember, it is about review, delay and deny with insurance companies, and if they can find a way to legally delay and deny the will most of the time do it because they usually place profits ahead of what is best for you medically speaking. This work comp insurance review process is called an “Utilization Review” (UR), and is conducted either by the work comp insurance company itself or by an outside company that is paid by the insurance company. Thus, it is common for a UR review of the treatment recommended by your own medical doctor to end up with the result of a quick denial of that treatment by the insurance company. Delay, deny, delay, deny becomes the mantra at this point. However, do not despair - you need a good work comp attorney to navigate this legal and medical process. Also remember, included with your legal rights to medical treatment is the right to be reimbursed by the insurance company for the distance you travel to get to and from your doctor’s appointments. Also, if you are called for a deposition at at later date, you get mileage reimbursement for that too - but this is for a different blog posting. Just know that sometimes when you go through California work comp medical care, there can be both "hills and valleys," and you need a good work comp lawyer on your side to help navigate those "hills and valleys."