Considerations for Choosing a Medical Provider for Workers’ Compensation Injuries

Workers’ compensation covers benefits for your employees if and when they are injured on the job. It can provide flexible compensation for things like doctors’ appointments, surgeries, physical therapy, medications and other treatment.

When it comes to treating work-related injuries, selecting the right doctor is paramount and can make all the difference when it comes to helping an employee return to work quickly. However, there are a number of considerations and specific guidance when it comes to selecting a medical provider for workers’ compensation injuries.

Selecting the Treating Doctor in a Workers’ Compensation Claim

When it comes to connecting an injured employee to the care they need following a covered injury, it’s important to remember that every state is different and has unique rules. Failing to follow these rules can lead to an insurance company’s refusal to pay for treatment.

When it comes to injuries covered by workers’ compensation, all states allow employees to receive emergency care from the nearest facilities when needed.

Outside of that, rules related to choosing a medical provider vary by state and generally fall under one of three options:

1. The employer chooses the treating doctor on behalf of the employee – in some cases, employees must use an employer-selected treating doctor for work-related injuries. This can help employers reduce costs and better manage workers’ compensation claims.
2. The employee chooses a doctor from a list or medical network provided by their employer – Some states allow employers to go through a preferred provider plan, network or managed care organization to treat an employee’s work-related injuries. Through this method, employees must select a treating doctor who is within the specified network.
3. The employee chooses any authorized doctor – Some states allow employees to choose their own treating doctor, particularly if an employer doesn’t have a preexisting provider plan or partnership with a managed care organization. Other states do not dictate who the employee sees for treatment at all. Also, employees typically aren’t allowed to use holistic or alternative medicine providers. Furthermore, there may be specific requirements employees must follow in order to receive care. For instance, an employee may be allowed to use their own primary care physician for a work-related injury, but only if they first give their employer written notice.

Each of these options has its own set of unique benefits and drawbacks. Employer-selected treating doctors can save organizations money and simplify the workers’ compensation claims process. However, when an employer limits or chooses what doctor an employee is allowed to use for work-related injuries, employees may feel as if there is a conflict of interest at play. It’s not uncommon for injured employees to worry that employer-selected treating doctors – whether they are chosen directly by an employer or by the employee via an approved list – don’t have their best interests in mind. In other words – whether justified or not – an employee may be concerned that an employer-selected doctor is more focused on saving the employer money and not on treating their injury.

For employee-selected treating doctors, conflicts of interest are no longer a concern. However, the employee-selected doctor may not be familiar with the workers’ compensation process, which can complicate treatment and extend the return-to-work process.

Finding the Right Treating Doctor

• Employee-selected providers:
  • Does the treating doctor has availability?
  • Does the treating doctor have the experience necessary to treat the injury or condition?
  • Is the treating doctor willing to accept the workers’ compensation medical fee schedule?
  • Does the treating doctor understand the workers’ compensation claim process? Are they willing to provide detailed reports in support of the claim as appropriate?
• Employer-selected providers: 
  • Will the health care provider treat workers’ compensation patients? Are they familiar with the workers’ compensation claims process and acceptable treatments?
  • Is the provider willing to accept the workers’ compensation medical fee schedule?
  • Does the facility offer care beyond emergency or urgent care visit? Can employees schedule follow-up appointments at the care facility?
  • Does the provider have an occupational health clinic? It’s worth noting that occupational clinics are typically more reserved with their workers’ compensation treatments – saving employers and insurance companies money.
  • Is the health care provider located close to the organization? If an employer has multiple locations, it’s important for them to seek a provider that has a larger network of facilities in multiple, convenient locations or one that offers telemedicine options.
  • Is the health care provider easy to work with and contact?
  • Does the provider follow proper billing requirements?
  • Can the employer schedule an appointment with the provider to discuss their operations and common job tasks? When providers understand the scope of an employer’s work, they are better equipped to understand and treat work-related injuries.

Again, rules related to choosing a medical provider for workers’ compensation injuries are complicated and vary from state to state. To navigate these requirements effectively, be sure to work alongside qualified insurance and legal professionals.

This Work Comp Insights is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel or an insurance professional for appropriate advice.