Manual Accidents Waiting to Happen: Best Practices in Workers’ Comp Administration

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Contents

  1. Best Practices in Workers’ Comp Administration
  2. New Mexico Workers' Compensation Laws
  3. Skip links
  4. 8 Facts You Should Know About GA Workers' Comp Law
  5. Follow the Author

If UR denies or modifies a treating physician's request for medical treatment because the treatment is not medically necessary, you can ask for a review of that decision through IMR. Along with the written determination letter that denied or modified your requested treatment, you will receive an unsigned but completed IMR form and addressed envelope. If you disagree with the decision, you must sign and send this form in the envelope to start the IMR process. What happens if I was treated and the claims administrator won't pay for it?

Do I have to pay? You most likely will not have to pay. This is a problem your doctor and the claims administrator need to work out. A medical provider network MPN is a group of health care providers set up by your employer's insurance company and approved by DWC's administrative director to treat workers injured on the job. Each MPN includes a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine.

If your employer is in an MPN your workers' compensation medical needs will be taken care of by doctors in the network unless you were eligible to predesignate your personal doctor and did so before your injury happened. A health care organization HCO is an organization certified by the DWC to provide managed medical care to injured workers. Your primary treating physician PTP is the physician with the overall responsibility for treatment of your injury or illness. Generally your employer selects the PTP you will see for the first 30 days, however, in specified conditions, you may be treated by your predesignated physician or medical group.

If a physician says you still need treatment after 30 days, you may be able to switch to the physician of your choice. This is a process you can use to tell your employer you want your personal physician to treat you for a work injury.

You can predesignate your personal doctor of medicine M. The DWC has a form for predesignating a personal physician on the forms page of its website. I would like to be treated by my personal chiropractor or acupuncturist. How does that work?

Accidents Waiting to Happen: Best Practices in Workers' Comp Administration

If your employer or your employer's insurer does not have a MPN, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness.

There is a form you can use called the notice of personal chiropractor or personal acupuncturist. After your claims administrator has initiated your treatment with another doctor during the first 30 day period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist. If you were injured on or after Jan.

Once you have received 24 chiropractic visits if you still require medical treatment, you will have to select a new physician who is not a chiropractor. The 24 visit cap does not apply to injuries that occurred before Jan. Also, the cap does not apply if your employer authorizes additional visits in writing. Additionally, the cap does not apply to visits for certain postsurgical physical medicine and rehabilitation services.


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You can also ask for a 2nd and 3rd opinion from different MPN doctors. If you still disagree, you can have an IMR to resolve the dispute. See the information on your MPN provided by your employer. What if I disagree with the MPN doctor's opinion regarding my ability to return to work, whether I'm permanently disabled, or if I need future medical treatment?

Best Practices in Workers’ Comp Administration

If you disagree with your MPN doctor on any issues other than diagnosis or treatment, you must request a qualified medical examiner QME. You, your treating doctor, your employer and your attorney if you have one should review your job description and discuss the changes needed in your job. For example, your employer might give you a reduced work schedule or have you spend less time on certain tasks.

If you disagree with your treating doctor, you must promptly write to the claims administrator about the disagreement or you may lose important rights.

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New Mexico Workers' Compensation Laws

I don't have an attorney and I have a disagreement about what my doctor report says about my injury. What should I do? You may request a medical evaluation with a physician called a qualified medical evaluator or QME:. If you are represented, your attorney and the claims administrator may agree on a doctor to examine you. Ask your treating physician to help if you don't know what kind of doctor should look at your injury.

QME lists are randomly selected and do not represent your employer or the insurance company. You have 10 days from the date the list is printed and mailed to select a QME from the list, make an appointment and tell the insurance company which doctor you picked and the date of your appointment. If you don't do this within 10 days, the insurance company will have the right to pick the doctor you'll see and make the appointment. What if the claims administrator has sent me a QME panel request form?

You might need to see a QME if the insurance company disagrees with something in your claim. In that case, the insurance company will give you the form to request a QME. If you don't send the form within 10 days of receiving it, the insurance company will have the right to request the QME list and select the kind of doctor you'll see.

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You have 10 days from the date the list is printed and mailed to select a QME from the list, make an appointment and tell the insurance company which doctor you picked, and the date of your appointment. A QME must be a physician licensed to practice in California. QMEs can be medical doctors, doctors of osteopathy, chiropractors, psychologists, dentists, optometrists, podiatrists or acupuncturists. If you have an attorney, your attorney and the claims administrator may agree on a doctor without using the state system for getting a QME.

The doctor they agree on is called an agreed medical evaluator AME. If they cannot agree, they must ask for a QME panel list. There could be other disagreements over medical issues in your claim. A doctor has to address those disagreements. You might disagree over:. Yes, but you have a limited amount of time to decide if you agree with the QME's report or if you need more information.

When you receive the report, read it right away and decide if you think it is accurate. If not, and you have an attorney, you should talk to him or her about your options. If you don't have an attorney, and you believe there are factual errors in the QME's report, you can request factual correction of the report by making a request within 30 days of receipt of the report.

Upon receipt of a request for factual correction of the report, the QME is required to file a supplemental report with the DEU and state whether factual correction is necessary to ensure accuracy of the report and, if so, whether the factual corrections change the opinions of the QME stated in the comprehensive medical report. If you are in a union, you may be able to see an ombudsperson or mediator under the terms of your collective bargaining agreement or labor-management agreement. Temporary disability TD benefits are payments you get if you lose wages because your injury prevents you from doing your usual job while recovering.

There are two types of TD benefits. If you cannot work at all while recovering, you receive temporary total disability TTD benefits. If you can't work your full schedule while recovering, you receive temporary partial disability benefit TPD payments. As a general rule, TD pays two-thirds of the gross pre-tax wages you lose while you are recovering from a job injury. However, you cannot receive more than the maximum weekly amount set by law. Your wages are figured out by using all forms of income you receive from work: wages, food, lodging, tips, commissions, overtime and bonuses.

Wages can also include earnings from work you did at other jobs at the time you were injured.

8 Facts You Should Know About GA Workers' Comp Law

Give proof of these earnings to the claims administrator. The claims administrator will consider all forms of income when calculating your TD benefits. Please see the benefits chart for current benefit rates. Any employee with earnings is entitled to TTD benefits. TTD payments will be paid at two-thirds the injured worker's wages at time of injury.

There are minimum and maximum rates for these benefits. Please consult the benefits chart for current rates. The minimum TTD will continue to be re-calculated each Jan. TD payments begin when your doctor says you can't do your usual work for more than three days or you get hospitalized overnight. Payments must be made every two weeks.

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Generally, TD stops when you return to work, or when the doctor releases you for work, or says your injury has improved as much as it's going to. If you were injured after Apr. If you were injured after Jan.

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Payments for a few long-term injuries such as severe burns or chronic lung disease can go longer than weeks. TD payments for these injuries can continue for up to weeks of payment within a five-year period. You don't pay federal, state or local income tax on TD benefits.

Also you don't pay Social Security, taxes, union dues or retirement fund contributions.