Q: My question is about workers compensation in California.
My husband's employer's TPA and UR personnel, and the state's IMR all denied him medical treatment requested by his orthopedic surgeon. Now they have informed him that since he was denied treatment he has to wait one year before his doctor can submit another request for treatment. A year is way too long to wait for treatment, so he is paying for his own medical treatment. He was awarded future medical treatment. It seems like California's future medical treatment award is a fraud. Although they denied him treatment, can he submit his medical bills to the TPA for reimbursement?
A:
1) Your husband does not need to wait a year for the requested treatment if the Treating Physician submits a new Treatment Request (RFA) citing different reasons why the treatment is necessary or if circumstances have changed substantially.
2) As for the billing, your husband can always direct the medical provider to the insurance carrier for payment and he can submit a request for reimbursement at any time. The tricky part is getting the carrier to make payment. Most often it simply ignores the request. So the first step is to submit the payment requests and see what happens. I believe the carrier gets 45 days to make payment so there will undoubtedly be some protests from the providers because of the delay in payment.
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