DWC’s Proposed Denial of Claims Notice Lacks Clarity

DWC’s Proposed Denial of Claims Notice Lacks Clarity

When an employer denies an employee’s workers’ comp claim, California law mandates that the employer must inform the employee of their right to seek medical treatment outside the workers’ comp system. This week the California Division of Workers’ Compensation (DWC) unveiled new proposed language that the employer must include when notifying the employee of the denied claim.

Having reviewed the proposed language, we worry that it is misleading. The DWC will welcome public comment until October 31st.

Signed into law in 2017, Senate Bill 1160 requires the DWC to adopt rules by Jan. 1, 2018, instructing employers to provide employees with notice that the employee can access medical treatment outside the worker’s comp system when the employer denies a workers’ comp claim.  Per a recent DWC Newsline, the proposed amendment to CCR § 9812(i) will require the Notice Denying Liability for All Compensation Benefits to contain the following statement:

“Although your claim has been denied, if you believe that you still need medical treatment for your injury or illness, you have the right to obtain treatment outside the workers’ compensation system.”

The above language seems straightforward and easily understood. However, the proposed language continues:

“If you have your own health insurance, or are eligible to be treated by someone else’s health insurance, you can use that insurance to get medical care. You should advise your physician that you believe that your injury or illness is work related, so the health insurer can seek reimbursement from the claims administrator. [emphasis added]

We believe the above-proposed language is misleading and confusing to all parties involved. This language is profoundly confusing about who, exactly, is financially responsible for payment and who, exactly, is responsible for chasing down that payment.

If their workers’ comp claim is denied, the employee is merely a patient — and is financially responsible for the medical treatment provided. While the employee may be contesting the denial of the claim, it is critical that the employee understands that they are ultimately financially responsible for the treatment received. Unless there is a change in the status of the workers’ comp claim, the employee must pay all medical bills.

In addition to the above, the proposed notification language also includes the following murky language:

“If you do not have health insurance available, there are doctors, clinics, or hospitals that will treat you without immediate payment. You should advise any doctor, clinic, or hospital that agrees to treat you that you believe that your injury or illness is work related so they can seek payment from the claims administrator through the workers’ compensation system.”

Again, the proposed language is grossly misleading to the injured worker. It suggests that providers 1) will treat them for free, and 2) will assume responsibility for fighting the denied claim for payment on behalf of the employee. We repeat, when an employer denies a workers’ comp claim, it is critical that the employee understands that they are ultimately financially responsible for the treatment received; the provider is not responsible for obtaining payment on behalf of the employee.

With the passage of SB 863, which requires the employer to authorize treatment, any provider that treats an injured worker without authorization is risking a financial loss. Per CCR § 9792.10.1, “Neither the employee nor the claims administrator shall have any liability for medical treatment furnished without the authorization…”  To the extent the claim is denied, the patient is liable for payment. The patient needs to understand their financial responsibilities.

For all parties involved, the language should be simplified and clarified. It should state plainly to injured workers:

When your work-related claim is denied...

  1. You may seek treatment for the injury outside the workers’ compensation system.
  2. You must advise the treating physician that you believe the injury / condition is work-related.
  3. Unless otherwise notified, you will be financially responsible for any and all treatment-related expenses.

We strongly encourage our readers to join us in pointing out the flaws in this proposed notice, while the DWC is still accepting comments. Visitors to the DWC website can make comments on the online forum for public comments, or email the DWC at DWCForums@dir.ca.gov by October 31.

Injured workers deserve clarity and straightforwardness, especially given the convoluted machinations of the California work comp system. When that system foists liability to pay for treatment onto the patient, a little transparency can’t be too much to ask.

DaisyBill offers everything providers need to ensure quick payment of bills for authorized services. Complete, compliant RFAs, original bills, and denial appeals are easy and fast with our tailor-made work comp Billing Software. Schedule a free demonstration for your office.


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