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L&I Medical Treatment

Your Right to Medical Treatment With an Open L&I Claim

An open L&I claim gives you a right to medical care for necessary and proper treatment related to your job injury. If you are injured, get medical care. First visit if you file a report of injury is always paid for. If your claim is accepted, then all treatment for accepted conditions should be paid for.

This is medical care for your L&I claim which covers job related medical or mental health conditions, while your claim is open. This is not health insurance. Medical treatment usually ends when the claim closes.

Your Choice of Doctors

Your first visit to a doctor after an injury is important because this is the doctor who will file your L&I claim.  It’s your choice, it is very important so get it right.

You may choose your own physician from L&I’s list of approved medical examiners and have the medical bills related to your job injury or disease sent directly to L&I for payment. There are special and complex rules for out of state treatment and non typical medical providers.

If you are seeing the wrong doctor, you can pick another doctor from the list of approved examiners. Do this if your doctor isn’t getting the job done.  There are L&I rules about changing doctors at WAC 296-20-065Having a good and supportive doctor is very important. 

Your doctor can refer you to specialists. Some specialists must be pre authorized by L&I or the Self Insurer.

Your doctor or the specialist can prescribe diagnostic tests. Some tests must be pre authorized by L&I or the Self Insurer.

The huge problem with the L&I medical care is that there are darn few good doctors who will treat L&I patients. There are many reasons for this.

  • L&I requires lots of paper work and most doctors don’t like that.
  • L&I uses IME’s to halt and regulate medical care. IME’s intimidate and annoy some doctors
  • L&I doesn’t pay doctors as much money as they can make elsewhere.
  • L&I is litigious, which means the doctor may have to go to court. Rare is the doctor who likes the courtroom.
  • L&I has encouraged the formation of large medical clinics where the doctors can be more easily controlled by L&I

Be Careful About Work Clinics and Some Doctors

  • See the wrong doctor and he or she will ruin your claim.
  • Under RCW 51.36.010 the worker is entitled to free choice of treating provider.  This is important! 
  • Understand this the doctor who files your claim if he or she continues to treat you will be your attending physician. The attending physician has a lot of say about how much help you are going to get while you are injured. Pick your own doctor carefully. Pick the wrong doctor and you will be sorry. For more information see:  Choice of Physician
  • You do not have to see a company doctor or work clinic. Your employer may offer to take you to an occupational medicine clinic after your injury.  You do not have to agree to see the doctor your employer recommends.  You can advise your employer that you appreciate their concern but you will see your own doctor, and that you will have your own doctor file the L&I workers compensation claim for you.
  • You should not allow any nurse case manager or other company representative to attend your medical exams. You have a medical privledge.
  • You do have to follow your companies after accident drug testing policy at a facility they choose.

How L&I Medical Bills Are Processed

  • The doctor’s office takes care of the bills. They bill L&I (Labor and Industries) or the SIE (Self Insured Employer)
  • L&I or SIE pay the doctor directly
  • The injured worker will never see a bill, unless there is a problem. If the injured worker has an open L&I claim and the treatment is related to the job injury, then the injured worker should not be billed. Doctors’ bills are discounted by L&I, but the worker should not be billed the difference       WAC 296-20-015(5)(h).

If a Medical Treatment Billing is Wrongly Denied, Figure Out Why & Take Appropriate Action

  • What is the reason given for not paying the medical bill? The reason should be on the remittance advice.
    • Is it a good reason? If not request reconsideration of their decision.
    • Is the billing in proper form?
  • Is coverage being denied for a good reason?
    • They are allowed to do this if they have scientific or factual support for their refusal to pay.
  • Is a bogus IME all they have? Don’t let them get away with that. If a treating doctor has knowledge that an IME is inaccurate, that treating doctor needs to speak up and make it right.
  • Is the billing for controversial treatment?
  • Does this treatment require authorization? WAC 296-20-03001
  • Is there a current and valid PPO contract governing bill payment? If there is a valid PPO contract on the date of service and it does not exclude workers’ compensation, then if valid it controls billing.
  • Take appropriate action if a bill is wrongly denied. How To Disagree With An L&I Decision

L&I and the Self-insurer are Regulated by and Should Follow the Law. The Following Questions and Answers will Help with Understanding the Law and Getting Treatment Bills Paid.

  1. Is the Self Insurer or L&I refusing to pay bills or refusing to pay a benefit in a timely fashion? – They are not allowed to do this so don’t let them get away with it. They can be assessed a 25% penalty which is payable to the injured worker. See : Penalties to the Self Insured Employer 
  2. Is L&I or the Self Insurer paying your doctor late? – Interest is due. The Self Insurer  RCW 51.36.085 and L&I RCW 51.36.080 must pay medical bills within 60 days of receipt of proper billing on an allowed claim. If they do not pay on time then interest is due and shall be paid at the rate of 1% per month.
  3. Is the Self Insurer trying to negotiate the fee schedule? They are not allowed to do this. They must pay per the fee schedule.
  4. Is L&I or the Self Insurer denying treatment for a condition they have previously paid for? The Court of Appeals in Clark County v. Maphet says they cannot do that.
  5. Take appropriate action if a bill is wrongly denied. Talk to your claims manager or bill payer. If that does not work then request reconsideration with a protest in writing, or file a written appeal to the BOIIA (Board of Industrial Insurance Appeals). You must protest or appeal in time, or you lose your right to do so because of the time limitation placed on protest and appeal rights. See: How To Disagree With An L&I Decision

Standard of Care and Maximum Medical Improvement

Medical care should be proper and necessary before it will be authorized. L&I defines this in WAC 296-20-01002 under “proper and necessary.”

Medical care ends with maximum medical improvement (MMI), or when the claim closes. There are very few exceptions.

Maximum Medical Improvement (MMI) is also know as fixed and stable. It is a place in the continuum of medical care where no further improvement in an accepted medical condition is expected. Said another way, in some doctors opinion, “it is as good as you are going to get.”

MMI is an important concept because L&I will not pay for additional medical treatment after MMI is reached. L&I takes the position that payment  for medical care is no longer proper and necessary once MMI is reached.

Keep in mind that MMI is not a fact, it is an opinion. L&I likes to push an injured worker quickly to MMI. They will do this with IME doctors. Be sure you and your doctor advocate for the necessary and proper medical care that you need to heal as well as possible.

Lifelong L&I medical care for an L&I claim is easy to say and hard to get.  It can be done, but it’s not easy. You or your attorney can ask for it in anticipation of claim closure. Also you can request to exercise your right to ongoing job related medical treatment after claim closure. After claim closure you will need to reopen the claim and the care requested must be proper, necessary, and causally related to your L&I claim. You must request and get a treatment order to effectuate this.

Medical Care for Unrelated Conditions

L&I pays for medical care if it is related to your job injury or occupational disease. L&I will not pay for conditions which are unrelated to your job injury . To get care for unrelated or denied conditions use your medical insurance (if any) or consider applying for Social Security Disability so you can get Medicare to pay. Read More About Social Security Disability and Medicare

Travel Expense for Medical Visits

Travel expense reimbursement is a benefit which some injured workers are eligible to receive. The benefit is small, and the rules only allow these benefits in some circumstances.  See: Travel Expense Reimbursement

Problems and Solutions: L&I Medical Treatment and Billing Information

Problem: L&I has scheduled an IME

Solution: Pay attention, this is important. L&I uses IME’s to end medical treatment and to close claims. Learn what you can do to help yourself. See:  Independent Medical Exam IME 

Problem: L&I denies the medical bills because the claim is not open.

Solution: Open a new claim, protest a recently closed claim, or re-open a previously closed claim.

Problem: L&I says my doctor is not in the network. 

Solution:  See: L&I’s Medical Provider Network – How to Find An L&I Doctor

Problem: Medical treatment is determined to be for a condition not accepted by L&I.

Solution: Get your doctor to help with this issue.  Often L&I is unaware of how your medical treatment is related to the job injury.  The attending physician has a lot of say about your medical condition and how it relates to your job of injury. If your job injury has caused a medical problem that needs treatment, make sure your doctor says so, in writing, to L&I.

For example if you hurt your right arm, you may end up overusing your left arm. At some point your overused left arm may become a natural complication and need medical treatment. L&I can and should pay for the medical care for this overuse problem. It’s your doctor’s job to convince the claims manager that your new arm problem, the overused left arm, should also become an accepted condition. If your doctor cares about you, he should do this for you and for himself.

The same is also true for mental health conditions. If you’re seriously injured and out of work you may get depressed. Depression is a natural complication of a serious and complicated job injury. It is a medical condition. Depression gets better with good mental health care. It can become an L&I accepted condition. Your attending physician is the person who can turn a medical condition into an accepted condition. He/she does it by writing to or speaking with the claims manager, and in the example of depression by referring you to a psychiatric specialist, who then may convince the claims manager to accept the mental health condition.

Problem: L&I sends you an order denying medical treatment saying it is unrelated to your job injury.

Solutions: That denial order should be protested or appealed. You have a right to medical care for conditions which are related to your job injury. See How To Disagree With An L&I Decision If L&I or the self insurer has previously paid for the treatment of the injury, then they cannot later deny acceptance.

As a temporary solution, when L&I denies a medical condition as unrelated, and you appeal, medicare or private insurance can step up and temporarily pay for treatment during the appeal period.  The two agencies can work out who pays the bills on their own, depending upon the outcome of your appeal.

If the Board of Industrial Insurance Appeals, after a hearing  and presentation of evidence,  denies a medical condition as unrelated, and that order becomes final, then that opens the door for an injured worker to get Medicare or  private insurance to provide diagnostic testing and medical treatment.

Problem: The Self Insured employer authorized and paid for surgery for an accepted condition. The self insurer denies additional surgery stating the industrial injury did not cause the need for additional surgery.

Solution: The denial of additional treatment should be protested or appealed.  The Court of Appeals in Clark County v. Maphet  applied  WAC 296-20-01002 and its definition of authorization and acceptance. The WAC states that because the Department or self insured employer can only authorize treatment for an accepted condition, as a matter of law, the Department or self insurer cannot later disclaim responsibility for a condition that was treated.

Problem: I have a job injury and healthcare insurance, but  my healthcare insurance doesn’t want to help with my workers’ compensation case.

Solution: Healthcare and L&I medical care  are two different systems.

  • Healthcare is not for job-related concerns and has nothing to do with your workers’ compensation claim. With an open L&I claim, health care should not pay bills for L&I accepted conditions. It can pay for medical conditions denied by L&I or medical conditions not related to your injury. Your health care policy decides what it will pay, so read the policy if you have questions.
  • Medical care for an L&I claim allows you to see any doctor, who accepts L&I patients. That doctor should bill the workers’ compensation system, either L&I or the self-insured employer. With a job injury you have a right to proper and necessary medical care.

Problem: L&I or the self insurer is refusing to authorize medical care or refusing to pay medical bills or other benefits, in a timely fashion.

Solution: Don’t let them do this, they can be assessed a 25% penalty. You can request a penalty by writing to L&I.

Problem: I can’t find a good doctor who will treat L&I patients.

Solution: This is a huge problem. See L&I’s Medical Provider Network – How to Find An L&I Doctor

Problem: I have moved out of Washington State and I cannot find a doctor to help.

Solution: Moving Out of State or Out of Country with a Washington L&I Claim

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