Whether currently working or now retired, firefighters have an expectation that they will be covered for medical care through workers’ compensation if they are injured on the job. When you receive an award for an injury through the workers’ compensation appeals board (either through a settlement or an actual hearing), firefighters believe they are covered for the rest of their life for any medical treatment required for that injury.
When I meet with firefighters, I often hear “I don’t care about the money, I just want to make sure I’m protected for lifetime care.” What exactly does that mean and is it truly unfettered access to medical care? Unfortunately the answer is “no” as there are restrictions on medical care for work related injuries and often these restrictions become a source of significant frustration. It becomes particularly problematic when the firefighter moves out of state and discovers that getting adequate medical care is a challenge.
First, a little history. In the good old days (pre 2004 and Arnold Schwarzenegger), lifetime or future medical care pretty much meant what it said. You could treat with any doctor anywhere as long as that doctor was willing to accept the workers’ compensation fee schedule in California. Treatment was fairly unlimited and whatever the doctor requested, whether it be physical therapy, testing, or surgery, it usually got approved.
In 2004, the legislature, acting under great duress from the Governor, passed a workers’ compensation reform bill that required all treatment to be in accordance with medical evidence guidelines and subject to “utilization review” (UR). UR meant the doctor’s treatment request would go through a review process with a UR company retained by the employer. That company submitted the treatment request to a doctor who would review it and determine if it met the evidence-based guidelines for that particular treatment. If the treatment was denied via UR, the injured worker would then be examined by an agreed medical examiner to address the issue. 99% of the time, the AME would overrule the treatment denial.
As part of the reform, the legislature also put strict limits on the amount of physical therapy and chiropractic treatments an injured worker could receive.. It determined that an injured worker would be limited to 24 sessions during his/her lifetime. Note…not per year but the entire lifetime.
In 2012, the legislature enacted legislation to further limit treatment. They created the concept of independent medical review which meant that any appeal of a UR denial would be submitted to a second review by a company retained by the state. The exam by an AME was eliminated and injured workers’ were now at the mercy of another review company to try and overturn the UR denial. Statistics show that less than 10% of the IMR applications actually overturn the original denial and 90% uphold the denial. That means you have less than a 10% chance of getting your treatment if it’s denied via UR.
Now let’s add insult to misery and move to May 2018 when the City of Los Angeles created a Medical Provider Network (MPN) for work-related injuries. By creating an MPN in accordance with laws governing work related injuries, the City now controls who you treat with. While you still retain the right to choose a treating doctor after the first 30 days from an injury, you have to select a doctor within the City’s medical provider. While the network is fairly broad and contains many excellent doctors, it also contains doctors and facilities that are difficult to deal with in scheduling appointments and doctors who are not sympathetic to the injuries firefighters sustain.
Well, what if your injury occurred prior to 2004, 2012 or May 2018? Do any of these changes apply to you? Can you thumb your nose at the City and say, “Sorry but I was injured in 2002 and I have an award for future medical care. I want to treat with Doctor X and you can’t do anything about it”? Unfortunately, the answer is again “no.” All of the legislative changes including the City’s creation of the MPN are retroactive and enforceable by the City.
If the doctor you’ve been treating with for years is not in the City’s MPN, the City can tell you to find a new doctor within the MPN. There are exceptions to this which include allowing you to treat for an additional year to allow a gradual change of doctors. Also, if you have an acute illness, you may be allowed to remain with your doctor but your doctor must justify this in writing. It’s also possible your doctor can become part of the MPN by completing paperwork that can be found on the MPN website. It’s not terribly difficult to apply but does require some effort on the part of your doctor.
Now let’s jump to the most common issue that arises with future or ongoing medical care. Your exit date in DROP has arrived and you are packing up and moving out of state. Whether it’s Nevada, Texas, Tennessee or any of the other states that don’t have state income tax, you now have to find a new treating doctor for your work-related injuries. Depending on your injury and where you are moving to, this can be challenging. If you move to a remote area in a new state, any type of medical treatment is going to test your skills because there just aren’t a lot of doctors in those areas. Whether it’s an orthopedist, internist, or dermatologist, the more remote the area, then the fewer choices of physicians. Compound that with finding a doctor who will treat you for work-related injuries and it becomes even more difficult.
Generally, once you move out of state, the “MPN” requirement disappears because the MPN only contains physicians in California. If the City’s MPN doesn’t exist in your new state, you’re free to treat with any doctor…..provided…that doctor is willing to accept your case and the California fee schedule for payment of services. In addition, your doctor must be willing to comply with the California workers’ compensation laws and regulations on preparing medical reports with appropriate treatment requests based on medical evidence guidelines. Many out of state doctors simply won’t do this and when that occurs, your chances of receiving recommended treatment is reduced. Claims adjusters will not accept a one line prescription from your doctor for any type of treatment because the treatment request still must go through the UR process and an appropriate request for authorization with a supporting report must be submitted.
If you are moving to a state which has a workers’ compensation system that is known to be unfavorable to injured workers’, you difficulties in seeking treatment just increased. Texas and Florida are notorious for limiting workers’ compensation benefits and my clients who have relocated to those states struggle to find adequate care for their injuries.
So now you’re scratching your head and barking…..Well, gee Mr. Sherwin, thanks for the good news and painting such a wonderful picture of my retirement 3000 miles away. What, if anything, can I do about it?
Certainly investigating the availability of good medical care should be paramount to anyone planning to move out of state, whether it be for work-related injuries or not. Remember, the more remote your new home is, the more difficult it’s going to be to secure any type of quality care.
If your treatment is for a work-related injury and you do have an award for treatment, do a thorough search of the doctors in your area and investigate in advance any doctors who will treat California injuries. You might check with the local firefighter unions in your new area and see if there are doctors and facilities they recommend for their firefighters.
Work with your attorney, assuming you have one, to learn what is actually required for a doctor to submit a proper request for treatment. If a doctor takes the time to prepare a proper report, half of your battle is won.
While I painted a somewhat grim picture of treating out-of-state after retirement, there are still plenty of retirees who have succeeded in finding the right doctors to help them through their golden years. You worked hard for the City and gave them the best years of your life. You deserve to be treated fairly and properly for your injuries as you ride off into the sunset. Know your rights and how to exercise them. And most importantly, stay safe and healthy.
By Robert Sherwin of Lewis, Marenstein, Wicke, Sherwin, and Lee