Workers’ compensation is designed to and does cover a wide variety of treatment and types of care for workers who have sustained a work-related injury. Workers and providers can apply for payment for treatment associated with the care, and in some cases this will include home health care. Home health care may be required where an employee sustains an especially severe injury. In Frances Stevens vs. Outspoken Enterprises, Inc. (State Compensation Insurance Fund), the issue was whether it was proper for the Administrative Director to deny the plaintiff’s request for home health care based on an Independent Medical Review.
In this case, the plaintiff employee sustained a work-related injury. After being examined by her own physician, the physician recommended and requested home health care services. The employer requested an Independent Medical Review of this determination. The IMR applied the 2009 Medical Treatment Utilization Schedule Chronic Pain Medical Treatment Guideline and denied the plaintiff’s request to have the cost of her home health care covered under worker’s compensation. The court in a May 2017 opinion noted that there was extensive evidence that her need for home health care was “compelling,” and included extensive expert testimony to that effect. The court determined that the Administrative Director was wrong in applying the guideline and sent the case back to the lower court for further determination. The court stated that if the lower court decided the Administrative Director was wrong in denying the home health care after reviewing the available evidence, it may be appropriate to have a new IMR conducted.
The court ultimate determined that the 2009 Medical Treatment Utilization Schedule Chronic Pain Medical Treatment Guideline was not a “medical treatment necessity standard,” but rather was a standard for Medicaid reimbursement, and the decision was outside the Administrative Director’s authority, pursuant to labor code section 5307.27. The court went on to point out that it was contrary to labor code section 4600(h) and California case law. The court held that the guideline should not have been “summarily applied.” Instead, the request should have been evaluated within the requirements of 4610.5(c)(2) and the MTUS.
If you have questions about the workers’ compensation system and whether your business is obligated to cover certain types of care, you should discuss this with an experienced attorney. Call us today at (714) 516-8188 for an appointment to talk about your business.