Today we recount a too-familiar story that starts with a workplace injury and ends with an injured worker in collections — all because California can’t muster the stomach to enforce California law and keep the most basic promise of workers’ comp.

California law is designed to protect injured workers. But arguably, the Division of Workers’ Compensation’s (DWC) own instructions seemingly establish a parallel system of underground regulations in contravention of the Labor Code.

We received strong responses to our recent articles on DWC instructions that seem to negate injured workers’ legal right to treatment prior to the claims administrator’s acceptance or rejection of liability for the injury. In an email to daisyBill, a California claims adjuster shared what they described as an “all-too-common scenario” faced by injured workers as a result of DWC policy.

According to the adjuster, after denial of authorization for treatment by the claims administrator, workers reportedly attempt to do exactly what the DWC instructs: use their own group health insurance to cover treatment for a workplace injury. The results are predictable…

“Depressing & Dystopian”

Like many of our readers (and ourselves), the adjuster was horrified to learn that the DWC actually advises injured workers to use their own insurance (or plead for care without immediate payment) while the claims administrator ponders whether or not to accept liability for the injury — for up to 90 days, per California Code of Regulations Section 9812.

It’s easy to understand the adjuster’s shock, considering the California Labor Code mandate that claims administrators authorize and pay for treatment prior to making their liability decision, no matter what is ultimately decided.

As the claims adjuster described it:

“...I was in disbelief at first until I saw the DWC-1 form for myself, replete with the specific quotation called out instructing injured workers to seek treatment through their own medical care [emphasis added]. This has gone far beyond being simply asinine & farcical to just plain depressing & dystopian.”

The claims adjuster then laid out a nightmarish situation that they reportedly encounter with some regularity. According to the adjuster, using one’s own insurance for a work-related injury tends not to go well, as follows:

“...let me lay out an all-too-common scenario from the myriad cases I’ve had to untangle…because the adjusters handling the files before me did not respond appropriately to requests from medical providers, employers and injured employees.

1. An injured worker presents to the clinic but the [claims] administrator refuses to authorize treatment and the employee is turned away.
2. Rather than deal with an adjuster who almost certainly will not return their phone calls, the employee gets fed up and uses their own [health] insurance.
3. The health insurance company gets a hold of their claim and reverses payment to the provider thereby forcing the provider to collect the FULL amount from the employee with no reductions to OMFS or whatever reimbursement scheme the health insurance carrier has in place.”
[emphases added]

As the claims adjuster explained, the injured worker is then left with a terrible choice:

1. Pay large medical bills out of their own pocket, or
2. Be sent to collections, harming their personal credit

The claims adjuster further alleges that even when a claims administrator accepts liability for an injury, payment is denied for all treatment any provider furnished to the injured worker prior to liability being accepted. The claims adjuster listed all the reasons the claims administrator is allowed to deny payment for the treatment provided during the 90 days the liability is disputed:

• The bill was not submitted timely, because of the amount of time elapsed while the injured worker wrestled with the claims administrator.
• The provider was not a member of the applicable Medical Provider Network (MPN) (whether that’s verifiable or not).
• Treatment was not authorized (whether that’s true or not).
• “No RFA was submitted” (whether that’s true or not).
• The bill is a “duplicate”

Or, as the adjuster put it, payment is denied simply because “<insert bogus rationale here>.”

These “bogus rationale” denials are essentially insurmountable for a provider, because the DWC has rigged Second Review appeals and Independent Bill Review to be nothing but a cynical and circular error of paperwork, deadlines, and $180 fees for providers.  

The adjuster’s message concludes with a sobering summation of the state of California workers’ comp from their perspective:

“Frankly, we were better off with the way things were before all of these defense-friendly tweaks (SB899, SB863, etc.) were put in place and the enforcement mechanisms left to rot in some forgotten basement in Sacramento. I used to believe that there was at least some modicum of fairness within the system, but getting to that point requires a herculean effort on behalf of injured workers who are already struggling to make ends meet…” [emphases added]

When even claims adjusters echo our outrage at injured workers’ treatment, it is a clear sign that something is very, very wrong with how California regulators and legislators manage workers’ comp — seemingly prioritizing the profit of claims administrators over the health of injured workers.

While daisyBill’s insights and data reflect mainly the experience of providers, the adjuster assures us that there is no shortage of horror stories from the employee perspective — and those stories confirm our worst suspicions of how payer-friendly regulations, lax enforcement, and the state’s general abdication of its role are impacting injured workers.

“There are a considerable number of stories on Reddit that demonstrate time and again what the employees are being subjected to…

It’s not right. And it really feels like we are in the minority when it comes to giving a rat’s hind-end about the people who get hurt on the job.”

We thank the adjuster for sharing this inside perspective, and urge all of us in this “minority” of injured worker advocates to be as vocal a minority as possible, until state authorities actually enforce the laws passed to protect injured workers.

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