Injured workers are entitled to reasonable and necessary medical care related to the work-related injury or illness. In most cases, worker medical care occurs over a short period of time, but in rare cases (for serious injuries), may be lengthy or extend for life. The goal of workers' compensation is to help workers return to work as quickly as possible.
If a worker is injured on the job, it is important to follow the process that initiates a workers' compensation claim. The worker may need ongoing medical care, or indemnity benefits, also known as lost-time wages.
Find out more about the process of initiating a claim.
- Seek treatment for job-related injuries or illnesses, or seek emergency treatment if necessary
- Notify the employer within 15 days of accident or injury, which could be by completing the Notice of Accident form and submitting to employer
- Communicate clearly with employer, adjuster, and health care provider
- Go to authorized health care providers
- Take prescribed medications as directed
- Notify employer when medically released to return to work, and ask for work
- Sign the Notice of Accident form
- Encourage workers to get reasonable and necessary medical care
- Notify the insurer within 72 hours of the worker injury
- Notify the worker in writing on who will have first selection of a health care provider: employer or worker
- Communicate with worker and insurer in all stages of recovery
- Provide workplace accommodations for recovering workers, if possible
- If employer is hiring (pre-injury job or modified work), the employer shall offer to rehire the worker who has stopped working due to a workers' compensation injury
A worker is entitled to reasonable and necessary medical care. The employer's insurer will investigate all medical claims submitted by the employer. If a claim is found to be compensible, the insurer's claims administrator will pay the provider's medical bills. Bills should go directly from the HCP to the insurer. Employers should not directly pay for medical bills.
In workers' compensation, there is no balance billing. Workers should not be billed for amounts not covered by the insurer.
Generally, there are no out-of-pocket costs for medical care. Exceptions are for travel and medical cannabis expenses (see below).
Denial of Benefits
Workers who are denied care must establish that the injury occurred at or because of work. A health care provider may be needed to prove the work/injury connection. If a claim is denied, the injured worker can request the insurer provide a written statement on the basis for the denial. Depending on the information in the denial, the worker may want to call an ombudsman or consult with an attorney.
Health Care Provider Selection
The WCA does not refer or recommend doctors. In New Mexico, one party, either the employer or the worker, will choose the initial health care provider (HCP). The employer has first choice, but sometimes defers to the worker to make the first selection.
The employer should notify the worker in writing on who will make the first selection of the HCP. The insurer or self-insurance program may have a recommendation for the employer.
If an employer does not provide written communication on the HCP decision, any treatment is deemed authorized and will need to be paid for by the employer's insurer.
The selected provider is authorized for at least 60 days, after which the party that did not have first selection can opt to change to a different HCP. The 60 day choice runs from the date of first treatment, exam or consultation with the HCP.
Independent Medical Examination (IME)
An independent medical examination (IME) is sometimes necessary to clarify specific questions about an injury or illness. The evaluations help answer questions and help determine issues in a dispute. An IME is provided by a neutral provider who has not so far seen the injured employee. An IME can be requested by either party or mandated by a workers' compensation judge.
An IME provides a neutral assessment about a medical issue. They are paid for by the employer's insurer. IMEs can be performed by a single health care provider or by a panel of health care providers and specialists.
A worker who refuses to take part in an IME that has been ordered by a judge, may lose benefits. If a worker is unable to attend a scheduled IME exam, it is important to communicate with the adjuster. Insurers could ask to be reimbursed for any charges incurred for missed appointments.
The date of maximum medical improvement (MMI) occurs on the date at which no further recovery or lasting improvement to an injury can be reasonably anticipated. The treating HCP offers an opinion as to when this date occurs. For most employees, when MMI occurs, it is time to go back to work if the worker has not already returned. Temporary Total Disability (TTD) benefits are paid only until an injured worker returns to work at the pre-injury wage, or reaches MMI, whichever comes first. Medical benefits continue.
Find out more about non-medical benefits.
It is sometimes practical for a worker to use a HCP who is located outside of New Mexico. The claims administrator or ombudsman should be contacted before doing so. Special approval for this is also sometimes needed from the WCA Director.
Nurse Case Managers
Nurse case managers coordinate the health care services for an injured or disabled worker, and in general, are used only when the injury is serious. Nurse case managers can be assigned by the employer or insurer, or by the WCA. Workers can decline to use a case manager if assigned by the employer/insurer. If assigned by the WCA, however, use of a nurse case manager is mandatory.
Travel Benefits for Medical Care
Workers who travel 15 miles or more one way from home or work for health care can be reimbursed as part of their claim.
Workers should keep track of travel expenses, to include itemized receipts. They should submit timely requests to the claims adjuster.
Travel benefits include:
- Ticket cost for travel on commerical carrier
- Mileage reimbursement when worker has to travel 15 miles or more from home or work for medical care
- Hotel or lodging costs up to $85 if overnight stay is required
- Up to $15 for any one meal, with three meals total reimbursable in a 24-hour period, up to $30 daily maximum
Medical Cannabis for Medical Care
New Mexico allows an injured worker the use of medical marijuana when deemed "reasonable and necessary care" under the Workers' Compensation Act. The injured worker must pay out of pocket, and is reimbursed per fee schedule for the cost of medical cannabis deemed necessary in the workers' compensation claim.