Certified Specialist in California Workers’ Compensation

When you’re injured at work, California law entitles you to receive all medical treatment that is reasonably required to cure or relieve the effects of your injury. This includes doctor visits, surgery, physical therapy, medications, medical equipment, and any other treatment your doctor deems necessary.

But here’s the reality: Insurance companies routinely delay, limit, or deny medical treatment in an effort to save money. They use utilization review doctors, independent medical examiners, and bureaucratic tactics to avoid paying for the care you need.

You don’t have to accept this.

At the Law Office of Joseph T. Todoroff, we fight aggressively to ensure injured workers receive proper medical treatment. As a Board-Certified Specialist in Workers’ Compensation Law, Joseph understands the complex medical treatment authorization system and knows how to overcome insurance company obstacles.

Your recovery depends on getting the right medical care at the right time. We make sure that happens.

• Doctor visits and consultations
• Diagnostic tests (X-rays, MRIs, CT scans)
• Surgery and hospital care
• Physical therapy and rehabilitation
• Chiropractic care
• Prescription medications
• Medical equipment and devices
• Home health care when necessary
• Transportation to medical appointments

Treatment Must Be:

• Reasonably required to cure or relieve the effects of your injury
• In accordance with evidence-based medical treatment guidelines
• Provided by physicians within the Medical Provider Network (MPN) or approved by the insurance company

No Co-Pays or Deductibles Workers’ compensation medical treatment is provided at no cost to you. You should never receive a bill for authorized treatment.

Lifetime Medical Care For serious injuries, you’re entitled to ongoing medical treatment for life—not just while your claim is open.

1. Utilization Review (UR) Denials

What is Utilization Review?

When your doctor requests medical treatment, the insurance company sends the request to a “utilization review” physician who reviews whether the treatment is medically necessary. These UR doctors work for companies hired by the insurance company—and they frequently deny treatment without ever examining you.

Common UR Denial Tactics:

• Claiming treatment isn’t medically necessary
• Arguing treatment doesn’t comply with medical guidelines
• Requesting more information to delay decision
• Denying treatment that’s clearly appropriate for your injury
• Second-guessing your treating physician’s judgment

Why UR is Problematic:

• UR doctors never examine you
• They review only paper records
• They’re paid by insurance companies
• They often rubber-stamp denials
• They prioritize cost savings over your health

How We Fight UR Denials:

Independent Medical Review (IMR) When a UR physician denies treatment, we can request Independent Medical Review—a second opinion from an independent doctor not connected to the insurance company.

• IMR doctors are randomly selected
• They review your medical records
• Their decision is binding on the insurance company
• Must be requested within 30 days of UR denial
• No cost to you

Our Success with IMR: Many UR denials are overturned through IMR because independent doctors recognize the treatment is medically necessary. We prepare comprehensive IMR requests with supporting medical evidence to maximize approval rates.

2. Delayed Treatment Authorization

The Problem:

California law requires insurance companies to authorize or deny medical treatment within specific timeframes:

• Prospective (future) treatment: 5 working days from receipt of request
• Emergency treatment: 72 hours (automatically approved if not denied within this time)
• Expedited review: 3 working days for serious medical conditions

Common Delay Tactics:

• Claiming they didn’t receive the treatment request
• Requesting additional information repeatedly
• “Pending review” status that drags on for weeks
• Administrative “glitches” and lost paperwork
• Routing requests through multiple departments

Why Delays Are Harmful:

• Your injury worsens without treatment
• Delayed surgery can lead to permanent damage
• Pain and suffering continues unnecessarily
• Recovery takes longer
• Medical complications can develop

How We Fight Delays:

We take aggressive action when insurance companies violate authorization deadlines:

• File expedited petition with WCAB
• Request sanctions against the insurance company
• Demand immediate authorization
• Document violations for penalty requests
• Ensure you get treatment promptly

Important: If treatment isn’t denied within the required timeframe, it may be deemed automatically authorized. We enforce these deadlines.

3. Medical Provider Network (MPN) Issues

What is an MPN?

Most employers use a Medical Provider Network—a group of doctors, specialists, and facilities that have contracted with the insurance company to provide workers’ compensation treatment.

MPN Rules:

• You must generally treat within the MPN
• You can choose any doctor within the MPN
• You have the right to change doctors within the MPN
• After certain timeframes, you may be able to treat outside the MPN

Common MPN Problems:

Limited Specialist Access

• MPN doesn’t include the specialist you need
• Nearest MPN provider is too far away
• Long wait times for appointments
• MPN specialists have poor reputations

Inadequate Provider Directory

• Out-of-date contact information
• Providers no longer accepting workers’ comp patients
• Providers listed who don’t actually treat your type of injury

Difficulty Changing Doctors

• Insurance company won’t approve change of physician
• Claims you haven’t met requirements to change
• Limited options within MPN

How We Fight MPN Issues:

Predesignation If you designated your personal physician in writing before your injury, you can treat with that doctor instead of MPN providers.

Change of Physician Rights

• One-time change after 30 days
• Additional changes with employer agreement or good cause
• We help you navigate the change process

Treating Outside the MPN In certain situations, you can treat outside the MPN:

• MPN doesn’t have appropriate specialists
• Geographic access issues
• Emergency treatment
• MPN not properly implemented

We analyze your specific situation and fight for access to the best medical care—whether inside or outside the MPN.

4. Independent Medical Examination (IME) Disputes

What is an IME?

Despite the name, “Independent” Medical Examinations are anything but independent. Insurance companies send you to their own doctors to examine you and provide opinions about your injury, treatment needs, and disability.

The Reality of IMEs:

• IME doctors are hired and paid by insurance companies
• They frequently minimize injuries
• They often recommend stopping treatment
• They dispute causation of your injury
• They provide opinions favoring the insurance company

Common IME Problems:

• Examining physician has bias toward insurance companies
• Brief examination (15-30 minutes)
• Doctor ignores or minimizes your complaints
• Report contains factual inaccuracies
• Doctor is not qualified specialist for your injury
• Examination is rushed and superficial

Your IME Rights:

• You must attend IMEs or risk losing benefits
• You can bring a witness or record the examination (with notice)
• You can request copies of the report
• You can object to examination frequency (no more than once every 6 months generally)

How We Fight Biased IMEs:

Challenge the IME Report

• Point out factual inaccuracies
• Highlight doctor’s bias and history
• Obtain rebuttal reports from your treating physicians
• Expose conflicts of interest

Request Agreed Medical Evaluator (AME) Instead of the insurance company choosing the doctor, both sides can agree on a medical evaluator:

• Generally more balanced and credible
• Selected from qualified specialists
• Report is given more weight by judges

Deposition of IME Doctor We can take the deposition of the IME doctor and cross-examine them about their opinions, methodology, and bias.

5. Qualified Medical Evaluator (QME) Process

What is a QME?

When there’s a dispute about your medical condition or treatment needs, a Qualified Medical Evaluator (QME) provides an independent evaluation. QMEs are physicians certified by the state to perform workers’ compensation evaluations.

When QMEs Are Used:

• Disputes over whether injury is work-related
• Disagreement about permanent disability rating
• Conflicts over future medical treatment needs
• Disputes about ability to return to work

QME Selection Process: The Division of Workers’ Compensation provides a panel of three QME names in your injury specialty. You and the insurance company each strike one name, and the remaining doctor becomes your QME.

Why QME Selection Matters:

Not all QMEs are equal. Some physicians:

• Consistently favor insurance companies
• Provide thorough, fair evaluations
• Have specific expertise in certain injuries
• Understand the legal nuances of workers’ comp

How We Help with QME Selection:

Research the Panel We research each QME’s:

• Reputation among applicant attorneys
• Track record on similar cases
• Areas of expertise
• Report quality and thoroughness

Strategic Striking We use our knowledge of QMEs to strike the least favorable option and preserve your chances of getting a fair evaluation.

Prepare You for the QME Examination

• Explain what to expect
• Review your medical history
• Ensure you bring all relevant records
• Advise on communicating your symptoms

Challenge Unfavorable QME Reports If the QME report is unfavorable:

• We can request AME instead
• Obtain rebuttal medical evidence
• Take QME deposition to challenge opinions
• Request a new panel if QME was inappropriate

6. Change of Primary Treating Physician

Your Right to Change Doctors

If you’re not satisfied with your treating physician, California law allows you to change doctors:

Within MPN:

• One-time change after 30 days
• Simply notify the insurance company and choose a new doctor from the MPN

Outside MPN:

• After one year of treatment, you can request to treat outside MPN
• With employer agreement
• If MPN doesn’t have appropriate specialist

Reasons to Change Doctors:

• Doctor isn’t providing adequate treatment
• You don’t feel heard or respected
• Doctor seems to favor the insurance company
• Long wait times for appointments
• Geographic inconvenience
• Personality conflict
• Need a specialist in your specific injury

How We Help:

• Navigate the change of physician process
• Ensure proper notification to insurance company
• Help you select a new physician
• Fight denials of change requests
• Assist with treating outside MPN when appropriate

7. Future Medical Care Awards

What is Future Medical Care?

Even after your workers’ compensation case settles, you may need ongoing medical treatment for your injury. Future medical care ensures you continue receiving necessary treatment.

Two Types of Future Medical Care:

Ongoing Medical Treatment If you don’t settle your case completely (Stipulations with Request for Award), you retain the right to ongoing medical treatment for your injury for life.

Future Medical Care in Settlements If you settle via Compromise and Release (lump sum settlement), you typically give up future medical care. However, you can:

• Set aside Medicare Set-Aside funds for future treatment
• Keep the case open for medical treatment only
• Negotiate for higher settlement amount to cover future medical costs

Common Future Medical Treatment Needs:

• Ongoing pain management
• Periodic injections or procedures
• Future surgery
• Continuing physical therapy
• Prescription medications
• Medical equipment replacements
• Regular monitoring and follow-up

How We Protect Your Future Medical Rights:

We carefully evaluate:

• Your likely future medical needs
• Cost of anticipated future treatment
• Benefits of keeping case open for medical vs. cash settlement
• Medicare Set-Aside requirements
• Tax implications of settlement structures

Critical Decision: Giving up future medical care in exchange for a lump sum settlement is a major decision. We ensure you understand the implications and negotiate settlements that adequately compensate for future medical needs.

Step 2: Doctor Submits Request for Authorization (RFA)

Your doctor’s office submits a Request for Authorization form to the insurance company, including:

• Specific treatment requested
• Medical justification
• Relevant medical records
• Treatment guidelines supporting the request

Step 4A: If Approved

You can proceed with the authorized treatment at no cost to you.

Step 4B: If Denied

The insurance company must provide written denial citing specific reasons and informing you of:

• Right to request Utilization Review reconsideration
• Right to request Independent Medical Review (IMR)
• 30-day deadline to request IMR

Warning Signs You Need Legal Help

Immediate Red Flags:

• Your doctor says you need surgery but insurance denies it
• You’re in severe pain but treatment requests are denied
• Authorization delays exceed legal timeframes
• Insurance company stops paying for treatment mid-course
• You’re forced to see IME doctors repeatedly
• MPN doctors aren’t providing adequate care

• Right to all medical treatment reasonably required for your injury
• Right to choose your doctor within the MPN
• Right to one free change of physician after 30 days
• Right to timely authorization (5 working days)
• Right to emergency treatment within 72 hours
• Right to Independent Medical Review of UR denials
• Right to challenge biased IME reports
• Right to bring a witness to medical examinations
• Right to future medical care for serious injuries
• Right to treatment at no cost (no bills, co-pays, or deductibles)
• Right to legal representation at no upfront cost