Medical Termimology

Medical Fee Schedules

Official Medical Fee Schedule (OMFS)

This fee schedule is promulgated by the Administrative Director under Labor Code 5307.1 and Section 9790 et seq. of Title 8, California Code of Regulations.  It is used for payment of medical services required to treat work related injuries and illnesses. Copies may be ordered from the Department of General Services.  An order form (.pdf, 20k) can be downloaded from here.

Medical Legal Fee Schedule

The medical-legal fee schedule is contained in Section 9795 of Title 8, California Code of Regulations. It is used to reimburse physicians for preparing medical evaluation reports that are used in workers' compensation cases.

Interpreters Fee Schedule

The fee schedule for interpreter services when required during a medical examination is contained in Section 9795.3 of Title 8, California Code of Regulations.

Inpatient Hospital Fee Schedule

This schedule regulates the fees for hospital services provided to injured workers who have been admitted as inpatients. Mandated by the 1993 reforms, this new schedule is contained in Section 9792.1 of Title 8, Califonria Code of Regulations. Please note that there is a separate "definitions" section (9790.1) which applies to this schedule and three appendices.  An electronic copy of the "Payment Impact File," used to determine the  composite factors contained in the regulations, may be downloaded here (.zip, 117k).  This compressed file contains two documents, the data file (the FY 1998 Prospective Payment System Payment Impact File, September 1997 Update, published by the federal Health Care Financing Administration) and explanatory material in a rich text formated Word document.

Frequently Asked Questions

Answers to many of the questions DWC receives regarding the new fee schedules can be found here. Another information resource available for download is the Power Point presentation (.zip, 117k) used at training sessions conducted by DWC.

Managed Care Program - HCOs

The Managed Care Program reviews applications from health care organizations and certifies them for the delivery of managed care services under California workers' compensation law. Further information, including application requirements for certification and a list of certified HCOs, can be found on the managed care/HCO page.

Physician Reporting Requirements

California's workers' compensation system has a number of requirements for reports from physicians to claims administrators. These include Doctor's First Report (DLSR Form 5021), the initial report and progress reports of an employee-selected physician, permanent and stationary reports from all physicians, and a variety of forms and reports from employer-selected physicians. Section 9785 of Title 8, California Code of Regulations, covers these reporting requirements, which are essential to communications between claims administrators and medical providers. These regulations were amended effective Jan. 1, 1999 to require all physicians, however selected, to make the same reports and require detailed treatment plans in all reports (DWC Newsline). The amended regulations also provide for two new forms, PR-2 Primary Treating Physican's Progress Report, and PR-3 Primary Treating Physican's Permanent and Stationary Report.

Utilization Review Standards

Section 9792.6 of Title 8, California Code of Regulations, sets forth utilization review standards applicable to workers' compensation insurers and self-insured employers. Insurers and self-insured employers who opt to engage in case by case review of the medical treatment provided to injured employees in order to manage costs and improve care must comply with these standards, which were mandated by the 1993 workers' compensation reforms. Further information is contained in a 1995 DWC Newline announcing adoption of the standards by the Administrative Director. On Jan. 1, 1999, further revisions to these regulations went into effect, as noted in this 1998 DWC Newsline.

Industrial Medical Council

The Industrial Medical Council sets standards for Qualified Medical Evaluators (QMEs) and establishes policy and guidelines on treatment and evalution for injured workers. Resources available at the IMC  web site include:
• Medical Practice in the California Workers' Compenstion System (.pdf), a Guide for Physicians, and.
• Treatment and Evaluation Guidelines developed by the IMC.

Reports, Studies

• Utilization Review in California's Workers' Compensation System: A Preliminary Assessment A research brief, published July, 2001 (.pdf, 68k)
• DWC selected to conduct new NIOSH Study of return-to-work decisions by physicians in lower back injury cases (DIR News Release)
• Medical Report Reference Materials, a collection of guidelines for the workers' compensation community to help medical providers write complete medical reports for rating purposes (.pdf, 59k)
• Injured Worker Satisfaction with Care in a 24-Hour Pilot Program DWC Report (.pdf, 128k)
• 24 Hour Pilot Programs under Labor Code Section 4612 Interim Report to the Legislature, March 1997. Also available as an Adobe Acrobat file (.pdf, 113k).
  Quality of Care
• Improving the Quality of Care for Injured Workers in California, Focus Group Discussions, November 2001 (.pdf, 220k)
• What Do Injured Workers Think About Their Medical Care and Outcomes After Work Injury? A research brief, published May, 2001 (.pdf, 76k)
• Improving Quality of Care for Injured Workers in California, Workshop Synopsis, May 24-25, 2000 (.pdf, 16k)
• Workers' Compensation Health Care, Ad Hoc Quality Improvement Task Force, September 19, 2000, Minutes (.pdf, 28k)
• What Do Injured Workers Think of Their Medical Care? A report on the development of the patient satisfication survery. (.pdf, 137k)