Claims Administration: Physician Choice: Whose Right Is it?

 

 

When an employee suffers a work-related injury, workers’ compensation law obligates the employer to pay for medical treatment. Who gets to choose the treating physician—and why does it matter? In some states, the employer gets to choose the physician and all medical providers. This is called a full control program. In this type of system, covered employees can seek a second opinion if they are unsatisfied with their care and provide evidence that their care is inadequate, or if employers fail to notify employees of their rights or neglect to enforce their rights to full control. 

In a partial control program, employers select and post a list of medical providers. They can require employees to use an approved provider for a period of time specified by workers’ compensation laws. Medical providers must have the skills and qualifications to treat workers’ injuries or refer them to specialists with the employer’s approval. After the initial period of employer control, the employee may continue using employer-selected providers or choose their own. If employees feel their care is inadequate, they will have to submit to an independent medical exam, and the employer may suspend workers’ compensation payments until they comply. 

Some states have medical panels. In this type of system, the workers’ compensation jurisdiction (the state) maintains a list of approved medical providers. The employer and employee work together to select the providers that offer the best possibility of recovery. This model occurs most frequently in monopolistic states, in which the state’s workers’ compensation organization pays all claims. 

Finally, some states, including California allow free choice. Employees can use whatever licensed providers they choose. However, in California, employees must designate a "primary treating physician" before they are injured. Employees must provide their employer with the name of a licensed medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or a medical group with an M.D. or D.O. as the doctor with overall responsibility for treating their injuries. If employees do not predesignate a doctor, they must select a doctor from the employer’s medical provider network. If the employer does not have a medical provider network, employees must use an employer-selected doctor during the first 30 days after injury. 

Priorities for treating injuries under a group medical plan and a work-related injury differ greatly. In both cases, providers and payers want to provide cost-effective treatment so employees can fully recuperate. But because workers’ comp claims can also involve lost-time payments, using a more expensive treatment could be more cost-effective if it reduces lost work time. Occupational health specialists understand this. They can also provide guidance and support to make rehabilitation more likely to succeed.  

Although claimants perpetrate some types of workers’ compensation fraud, such as passing off non-work injuries as work-related or malingering, physicians can also be guilty of fraud. Dishonest medical clinics, or claims mills, can scam insurers out of millions of dollars by inflating injuries or giving illegal kickbacks to workers. Others might have no licensed doctors and little useful medical equipment. The use of medical provider networks helps both employers by ensuring that employees will be treated by pre-screened providers who’ll provide quality, cost-effective care of workers’ compensation injuries.