Workers' Compensation—General. A worker who is injured in the course of employment or injured or disabled from an occupational disease is entitled to workers compensation benefits under the Industrial Insurance Act. Benefits may include medical, temporary time-loss, vocational rehabilitation benefits, and permanent disabilities benefits. The Department of Labor and Industries (L&I) administers the workers' compensation system.
Accident Reporting and Notice. If a workplace accident occurs and the worker receives treatment from specified health care providers, the worker must report the accident to the employer and the employer must report it to L&I. L&I must notify the worker of the worker's rights to receive health services from a provider of the worker’s choice, and must list the types of providers authorized to provide services.
Medical Provider Network. An injured worker must seek medical care from a provider of the worker’s choice within L&I’s medical provider network (network), except for an initial office or emergency room visit. The injured worker must select an attending provider from the network for all care beyond the initial visit. Non-network provider types may provide treatment as directed by the attending provider.
The professions listed as attending providers must be enrolled in the network. Applicants must meet certain standards and be approved by L&I to become a member of the network.
Coverage Decisions and Treatment Guidelines. Network providers are required to follow L&I's evidence-based coverage decisions and treatment guidelines, policies, and are expected to follow other national treatment guidelines appropriate for their patient.
Continued Treatment in Permanent Total Disability Cases. For permanent total disability claims, covered treatment ends on the date of a lump sum settlement or when the worker is placed on a permanent pension. The Supervisor of Industrial Insurance may authorize continued treatment for previously accepted conditions when necessary to protect the worker’s life or for the administration of medical and therapeutic measures. Advance authorization is required for such treatment.
Utilization Review. The utilization review (UR) process compares requests for medical services to evidence-based treatment guidelines and includes a recommendation based on that comparison. L&I information provides that UR is required for:
L&I contracts with a third party for the UR process. If a request meets the guidelines or criteria, approval is recommended. If the request does not meet the guidelines or criteria, a physician review is initiated. If a physician reviewer is unable to recommend approval, the provider will be notified and the requesting provider may discuss the request with the third-party reviewer or provide additional information. Detailed clinical reports are submitted to L&I. Options for re-review are detailed in the communication to the provider and in the L&I letters. The claim manager will issue the final determination and inform the requesting provider.
Worker’s Provider Choice. An employer must inform an injured worker that the worker has a right to seek initial or emergency medical treatment from a provider of the worker's choice and to seek further treatment with a provider of the worker's own choice from within the medical provider network. Nothing prevents an employer from providing on-site medical care to a worker at the worker's own choice.
An employer may not require or induce an injured worker to seek treatment from a specific provider or clinic. L&I must investigate any allegation that an employer attempted to require or induce an injured worker to seek treatment from a specific provider or clinic.
A violation by a self-insured employer is a violation of the statutory duty of good faith and subjects the employer to penalties. A violation by other employers subjects the employer to penalties for claim suppression.
If a worker is unable to find a provider in the network who is willing to treat the worker within a specified distance from their home, the worker may provide notice of this fact to L&I or self-insured employer. Within ten calendar days of receiving such notice, L&I or self-insured employer must send the worker a declaration to sign certifying this fact. Upon receipt of the signed declaration, L&I or self-insured employer will have ten calendar days to assist the worker in finding a provider in the network or who agrees to join the network to treat the worker. If no provider is found, the worker may seek treatment from a non-network provider within 15 miles of the worker's home, if the worker resides in a county with a population of 500,000 or more, or within 30 miles of the worker's home, if the worker resides in a county with a population of less than 500,000, and if the provider agrees to be paid under the L&I fee schedules and sign a non-network provider agreement.
If the worker has met the conditions, the worker may immediately receive treatment from a non-network provider, regardless of whether the provider has completed a non-network provider agreement or application to the medical provider network. Provision of treatment to the worker serves as the provider's agreement to follow the department's medical aid rules and fee schedules.
Coverage Decisions and Treatment Guidelines. A network provider may deviate from the L&I's coverage decisions, treatment guidelines, policies, or national guidelines when medically appropriate.
Utilization Review. Utilization review must be completed within ten business days of the date the utilization review provider receives all requested information necessary to make the treatment recommendation, or the treatment must be authorized.
Continued Treatment. In addition to cases of permanent total disability, the Supervisor of Industrial Insurance may authorize continued treatment in cases of permanent partial disability when deemed necessary and in specified circumstances. Advance authorization is not required. Continued cancer monitoring is covered at a frequency recommended by the worker's oncologist.
Written Notice When Removing a Provider from the Medical Provider Network. When L&I removes a provider from the medical provider network, it must be done in writing. The provider may appeal to the Washington State Board of Industrial Insurance Appeals.
Claims managers. L&I may hire additional claims managers to reduce case loads and reach an average case load of 141 claims per claims manager and based on a study beginning July 1, 2031. Moneys used are subject to allotment, not appropriation, from the accident fund.
The committee recommended a different version of the bill than what was heard. PRO: Industrial insurance is often called the grand compromise where workers give up the right to sue their employer when injured on the job in exchange for sure and certain relief, timely medical care and wage replacement. Before 2011, any licensed doctor meeting state requirements could treat injured workers, allowing people to stay with trusted providers. After 2011, providers were required to join the medical provider network and follow department issued treatment guidelines, which creates a more structured approach to care. In 2018, the Washington Supreme Court ruled in the Murray case that injured workers should receive individual determinations rather than relying solely on rigid guidelines. This bill will better support the medical decision-making of the attending physician.
Medical guidelines held by the department are useful, but often they're used to preempt the medical expertise of attending physicians, who are better able to assess the worker's care. The bill would codify the Murray decision.
Since the passage of the Medical Provider Network bill in 2011, it has become increasingly difficult for injured workers to access the care that they desperately need for their on-the-job injuries and to find treating providers. There has been increased delays or denials of necessary treatment, often resulting in lengthy and costly litigation. This bill will help solve many of the barriers to quality medical care for injured workers. It will return the injured worker's ability to choose the doctor to treat them. It will empower doctors to provide appropriate individualized care to injured workers as provided in the Murray decision.
There's a disconnect between what the people of the state are expecting from L&I and what workers are getting. Also L&I is picking and choosing when to use its own guidelines.
Under the current system, injured workers are not guaranteed care for permanent injuries. The bill ensures they're not cut off from medically necessary care simply because their claim closes and it protects medical independence.
The bill allows doctors to practice medicine as they are trained and qualified to do. It provides the same standard that you and I would enjoy under our private health insurance. It allows the doctors to go outside the parameters of the medical treatment guidelines when it's medically appropriate for our patients.
L&I recently issued a 34-page draft PTSD treatment guidelines and solicited feedback. Dozens of providers who care for first responders testify the policy is based off poor science and lacks real-world clinical experience. PTSD is not a one-size-fits-all situation.
CON: Balance is essential to maintaining trust in the system and this bill could risk that. L&I's guidelines are in place to maintain that balance. Without standards, we could see longer-claimed durations, higher costs, and less predictable outcomes.
We share the frustration over lengthy treatment approvals and the shortage of qualified providers. However, this bill is not the solution. It would weaken the medical provider network and allow intending providers to bypass the guidelines that claims managers rely on to make sound decisions. The network is critical because it promotes better medical outcomes through evidence-based care, controls costs by preventing unnecessary or harmful treatment, and removes poor performing providers.
For prohibition on requiring or in any way inducing a worker to treat with a particular provider or clinic. We would like to see the term induce defined or some sideboards because the penalties that automatically apply upon a finding of inducement are substantial. The prohibition is very vague and might cover things that are fairly innocuous in the workplace and meant to help workers, such as on-site first aid, on site occupational medicine facilities, providing a list of providers upon a worker's request that they might be able to treat them. We need to get some safe harbors and definitions.
The guidelines are usually made around conditions that are very prevalent, are highly variable in their treatment approach, or very high risk. IMAC will then engender a subcommittee to look at the evidence and create these treatment guidelines, including a survey of existing peer reviewed literature an epidemiologist and then the subcommittee deliberates on the evidence.
OTHER: The volume of claims that L&I accepts every year is more than 80,000 claims. For the vast majority of those claims, these guidelines are quite helpful. They are based on national studies and L&I's ability to look at worker improvements related to specific treatments and provide guidance to the medical providers. This is the intent of the guidelines. Medical access challenges are real and L&I fully supports efforts to reduce delays and improve access to high-quality medical care for injured workers. The concern is that this bill makes significant, untested changes to L&I's ability to ensure that medical quality and consistency. These changes may not resolve the most significant access challenge and would introduce risk for all injured worker. For most injured workers, the system works well. For a smaller share of workers, the process does not always move quickly or smoothly enough, and L&I is committed to improving that experience.
The challenge is getting the exceptions right. For the more complex cases we're balancing two types of risk. First, approving invasive treatment like surgery, when conservative care would have worked, exposes workers to pain, recovery time, and the risk of complications. Second, when conservative care is tried and does not work, workers may experience prolonged pain, frustration, and delays waiting for surgery. Getting this balance right requires thoughtful review, medical judgment, and flexibility, not removing the structure entirely. This bill represents a fundamental shift in how medical necessity for proper care decisions are made in the workers' compensation system. Improvements should be tested, targeted, and data-driven.
Although the stories are compelling, we do not feel there was a good stakeholdering process for the significant changes. Evidence-based medical guidelines should not become effectively optional. Any division must be medically appropriate based on patients specific or clinically extraneous circumstances and support by credible medical literature furnished by the provider.
Currently, employers are not allowed to compel workers to seek specific providers, but the word induce should be replaced with the word coerce. Also, employers should not be prohibited from providing neutral factual information to an injured-worker with information related to COHE or evidence-based programs. The penalty should be removed because the penalty is disproportionate to the behavior. There's no evidence that this is a widespread problem. The 15-mile rule is unrealistic. We need to consider rural, urban, the type of provider, whether specialized, and there needs to be lot more considerations to this restrictive rule.
For utilization review, there should be a pause of the 10-day timeline if L&I needs additional information, or if the provider does not respond.