What Role Does the Treating Physician Play in Workers’ Compensation?

by | Published on Mar 25, 2019 | Workers Compensation

An injured worker is entitled to reasonable and necessary medical care as part of workers’ compensation benefits. Medical chart review is an important requirement when determining an applicant’s eligibility for workers’ compensation benefits. It is based on this evaluation that the necessary treatment protocol can be initiated. The authorized treating physician has an important role to play in a workers’ compensation case. This physician prescribes and provides the medical care the worker requires to recover from a work-related injury, and also provides opinions regarding his/her capability to work, and permanent partial disability. The opinion of the treating physician carries considerable weight because he/she monitors the injured worker’s recovery over time. Therefore, this doctor will have a clear understanding of the injuries, the medical treatment required, the injured employee’s physical limitations and the possibility of a complete recovery.

What decisions does a treating physician make?

  • Provide a medical diagnosis and determine the medical treatment required.
  • Determine whether the injured worker would need time away from work for a smooth recovery – the doctor will also decide when the injured worker can return to work.
  • Refer the injured worker to specialists if needed.
  • Decide on the injured worker’s level of permanent disability. Once the injured employee reaches maximum medical improvement (the condition is stable and will no longer improve), the treating physician will determine whether he/she has any permanent limitations. The doctor’s inferences will be used to estimate permanent disability benefits for the employee.
  • The treating physician also provides valuable evidence in the form of medical records. Accurate medical documentation regarding the injury, treatment, and recovery will help avoid disputes with the insurance company. The treating physician may also have to testify on behalf of the injured employee in a deposition or at a workers’ compensation hearing.

Rules May Vary with Different States

Each U.S state has individual rules regarding where injured workers can obtain medical treatment. Some states allow workers to choose their own doctors from the very beginning. This is usually when the employer’s insurer does not have a network contract for workers’ compensation. Workers may have to make a selection from their state’s list of approved physicians for workers’ compensation. California allows workers to pre-designate their primary care doctor to treat the work injury, provided you designate the doctor before the injury. New York, Texas, and Ohio also allow employees to choose their treating physician. Some states, e.g. Pennsylvania, require employees to select a doctor from the employer’s established healthcare network or from a list of approved physicians. Yet other states like New Jersey and Florida allow the employer to choose the initial treating doctor.

What to Consider when Choosing a Doctor

When choosing a doctor, workers must consider certain important aspects such as the following:

  • The physician’s skill and experience
  • Whether he/she is familiar with the type of injury the employee has
  • Field of medical specialization
  • Whether the doctor is available for appointments
  • Whether the doctor is nearby the injured person’s home
  • Whether the doctor is willing to accept the injured worker’s state’s workers’ compensation medical fee schedule
  • Whether the employee feels comfortable with the doctor and trusts him/her

Treating physicians can be from medical specialties such as the following among others:

  • Occupational therapist
  • Chiropractor
  • Psychiatrist
  • Psychologist
  • Doctor of osteopathy
  • Dentist
  • Audiologist
  • Acupuncturist
  • Speech language pathologist

Can the Treating Physician Change?

Another important consideration is whether the authorized treating physician may change in the course of a workers’ compensation claim. The answer is yes, the physician may change in certain specific situations.

  • The treating physician may refer the injured worker to another doctor with greater expertise with the type of injury sustained. This new doctor will become the new authorized treating physician if the referral made is a direct one. If the referral is a generic one (the worker must see a specialist), the insurer has the right to offer a new panel of physicians that contain specialists and the injured worker must choose a new authorized treating physician from this panel.
  • The injured worker may find it difficult to get along with the authorized treating physician and want to change the doctor. If the insurance company allows changing physicians, it is good. Otherwise, the worker will have to file a claim requesting a change in treating physician.
  • The designated treating physician may release the injured employee from his/her care even if the employee continues to have symptoms. The worker will have to file a change in condition claim requesting a new panel of physicians or a change in authorized treating physician if the insurance company refuses to provide a new treating physician. In such cases, the Workers’ Compensation Commission will schedule a workers’ compensation hearing where the worker and the insurance company submit evidence and testimony. Based on this hearing, the Commission will provide a ruling.
  • The injured worker and the insurer may agree to change to a new authorized treating physician for other reasons. These reasons may be – the insurer does not like dealing with the physician’s administrative staff; or it takes too long to get an appointment; or the injured worker has moved and does not have transportation to the doctor’s office. It is important that the change to a new treating physician should be clearly expressed via a written agreement with the insurance company.

As providers of medical record review services for workers’ compensation lawyers, we know that injured employees planning to switch treating physicians should consult their attorney before doing so. This will ensure that they are following their state’s rules for selecting the treating doctor. If these rules are not followed, the insurance company may refuse to pay the medical bills. An experienced lawyer will help injured workers understand and steer through the complex workers’ compensation system and obtain the medical care they need.

Discover our medical record review solutions and partner with us for your next case.

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