Posted on Tuesday, May 22nd, 2018 at 12:39 pm
When a worker gets injured at work, they aren’t thinking about which doctor to go to. They are hurt and want medical attention and that’s about as far as the thought process goes. In contrast, the insurance company has already given the subject a lot of thought. Often insurance companies have pre-selected the doctor’s office they want an injured worker to treat with. While their medical treatment is not controlled by the insurance company directly, these offices are in long-standing relationships with the workers’ compensation carrier.
Under Kentucky workers’ compensation law, medical treatment is controlled by a “designated physician” this is a doctor the injured worker selects on what is known as a “Form 113”. Sometimes an insurance company will fill in the Form 113 with a physician’s office of their choosing. However, the injured worker has the right to pick their own doctor.
The selection of a Form 113 doctor is crucially important. This doctor is the “quarterback” of the injured worker’s medical team. They are the physician who calls the medical plays, so to speak. This doctor determines whether a referral to a specialist is necessary, and they often make a recommendation as to which specialist to see. This in turn determines whether an injured worker gets diagnostic testing such as MRIs and whether the injured worker gets surgical care.
For the selected doctor, the decision on medical care is actually twofold, not only are they determining whether they think there is a medical need for treatment, they are deciding whether or not the treatment is work-related. For example, let’s say you twisted your knee at work. If your doctor is of the mindset that you need surgery now but consider that part of that surgery is to treat an arthritic condition, they might determine that you cannot have the surgery under workers’ compensation coverage. This might be the case even though you 1) got hurt at work, 2) there were witnesses 3) you had never once received any kind of medical care for arthritis or for your knees in your entire life!
When a doctor makes this decision they are not necessarily following the law. In Kentucky it is well-established that if a worker has some kind of condition that pre-existed the work injury, but was dormant i.e. it never bothered them before the work injury so they weren’t under medical care for it and then the condition becomes problematic after the work injury then both the work injury itself AND the prior dormant condition can be treated under the workers compensation carrier coverage. If the injured worker is off work while this treatment is undertaken, they may qualify for income benefits.
This makes the doctor’s decision very important. If a doctor does not agree with the law, say, due to their political stance, or if the doctor simply is unaware of the law, the treatment and income benefits the injured worker is entitled to may get denied. As you can see, it is extremely important that an injured worker gets a treating physician that either already has an understanding of the legal ramifications of the decisions they make or is at least willing to listen and learn. Sadly, not all doctors are.
An understanding of the workers’ compensation system is not the only requirement for the right treating physician. An insurance company is in business to make money. They do not make money by paying for medical care or paying an injured worker income benefits. Therefore, they will do things to try and minimize the amount they pay out. One of the things the insurance company will do is challenge the medical treatment through a process called utilization review, or peer review. In these scenarios the insurance company has hired a doctor, or often a nurse, to review the records to see if they believe the injured worker should get the medical care their doctor asked for. The reviewer will not see the patient, not even once, they will often refer to what are called the Official Disability Guidelines, and commonly they will determine that the treatment is not compensable. In the denial they will often state that they attempted to call the treating doctor but could not get through. The treating doctor has the right to appeal the decision of the reviewer, but they have a limited amount of time. It is very important that the injured worker has a doctor who is willing to answer the call and to respond to the denial when it comes. If the doctor simply doesn’t bother, the injured worker may have to litigate just to get their medical care, and this can take months. If the injured worker gives up, then the insurance company saves a bunch of money.
The treating doctor has an important role to play in the amount of income benefits an injured worker receives. This is because these benefits are calculated using an impairment rating provided by the physician. Many times, a hired expert will give an opinion on the percentage of impairment, and a good attorney will know which experts to use. However, the Administrative Law Judges often consider the view of the treating physician to be very significant. If your treating doctor is unwilling to figure out your impairment, or if they are unfamiliar with the process, they will not be assisting your case.
The treating doctor will be the one who assesses work restrictions, in other words they determine whether an injured worker can go back to work. Often the insurance company will employ a nurse case manager who will question the doctor on this issue. The injured worker will want a physician that is willing and able to justify their decision on work restrictions under this kind of challenge.
At Lawrence & Associates we describe the physicians that do these things as “patient advocates”. While proper medical care is essential, patient advocacy is always very important too.