Finding a Treating Doctor in Your Workers' Compensation Case

Workers' compensation covers all reasonable and necessary medical treatment for a work-related injury or illness. This includes doctors' appointments, surgeries, physical therapy, medications, and other treatment. The doctor who treats your work injury will play an important role in your case—not only by overseeing all of your medical care, but also by giving opinions that will affect how much you receive in workers' comp benefits. For these reasons, it's important to find a treating doctor you can trust. But that search could be complicated by your state's limits on doctor selection.

Who Chooses the Treating Doctor in a Workers' Comp Claim?

The rules for getting medical treatment through workers' compensation vary from state to state. If you don't follow your state's rules, the insurance company may refuse to pay for your treatment. All states allow you to get the nearest available emergency care when that's needed. Beyond that, however, your choice of treating doctor may be limited, depending on where you live and who you work for.

The rules are often complicated, but your freedom to choose generally falls into one of three categories: (1) you choose a doctor from a list or medical network provided by your employer; (2) you choose any authorized doctor; or (3) your employer chooses the treating doctor for you.

Provider Networks or Panels for Workers' Comp Treatment

In many states, employers have the option of contracting with a preferred provider plan, network, or managed care organization to treat their employees' work injuries. This is an increasingly popular way for employers and insurance companies to reduce costs and control medical care for workers' comp cases. If your employer has a plan like this, you must select a treating doctor from within the network and follow its rules for getting medical care.

Certain states allow employers to present injured workers with a list (or panel) of doctors to choose from. These lists usually must contain a minimum number of doctors and specialists; often, there are limits on the number of occupational clinics that may be included.

Employee Selects the Treating Doctor

In some states—like New York, Texas, and Illinois—you have the right to choose your own treating doctor, as long as your employer doesn't have a provider plan or managed care arrangement. Typically, however, you need to choose from a list of health care providers that the state has approved for treating workers' comp injuries.

There may be extra requirements for choosing your own doctor. In California, for example, you may use your personal primary care physician as your treating doctor, but only if you have given your employer written notice before the injury that you want to do that; also, this option is only available if your employer offers group health coverage.

Employer Selects the Treating Doctor

In still other states, you have to go to a treating doctor picked by your employer, at least at first. Some of these states only require you to see the company doctor for your initial visit (as in Florida) or for a certain period of time before you change physicians.

Sometimes, workers worry that a company-selected doctor has a conflict of interest and might minimize their injuries. Unfortunately, this could be true in your case. You may be able to switch doctors if you believe you aren't getting adequate care, but you must follow the rules in your state for changing workers' compensation doctors.

Tips on Finding the Right Treating Doctor For Your Workers' Comp Case

You should do whatever you can to find the best treating doctor for you, even if you're limited to a network or a list of physicians. When you're speaking to potential doctors or their offices, consider their:

• experience and understanding of your medical condition
• willingness to accept the workers' comp medical fee schedule
• knowledge of the workers' compensation claim process
• willingness to support your workers' comp claim with detailed reports, and
• availability for medical appointments.

Above all, you should choose a doctor you trust and feel comfortable with. If you need help finding a treating physician, a workers' comp lawyer may have some recommendations. An attorney can also explain the rules in your state and help you if you want to change treating doctors or are having trouble getting proper medical care.