Under the Illinois workers’ compensation system, you have the right to any medical care that’s needed to treat an on-the-job injury. This includes doctor’s appointments, surgery, hospital stays, physical therapy, and mental and vocational rehabilitation.
In order to get your medical care covered, however, you need to follow the rules for choosing the primary doctor who will provide treatment or refer you to specialists. And your employer’s insurance company will need to approve the treatment or go through a process for reviewing whether it’s necessary. Read on to learn more about those rules and the process for getting the medical care you need.
The doctor you select to treat your work injury will play a crucial role in your recovery as well as how much you might receive in Illinois workers’ comp benefits. That’s because the treating doctor makes a number of important decisions, including:
Illinois has three different procedures for selecting a treating doctor, depending on the decisions the employer has made about providing medical care for workers’ comp injuries:
The requirements for selecting a doctor don’t apply to emergency care when you need it.
There are many reasons you might want to switch treating doctors. Maybe you don’t have a good relationship with your physician, or you think the provider is more concerned with your employer’s finances than with your recovery.
In Illinois, you’re allowed two choices of treating doctors during your workers’ comp case. That means you can only change doctors once without asking the insurance company’s permission. If you want to switch physicians a second time, you’ll need approval from your employer’s insurance company.
If your employer's insurer uses a PPP, your second-choice doctor must also be in the network. However, if you declined to use a network physician, that counted as your first choice. This means that the initial out-of-network doctor you selected is considered your second choice, so you can’t choose another treating physician without approval.
During your recovery, you might need more specialized care than your treating doctor can provide, like physical therapy or orthopedic surgery. The insurance company must also pay for those medical services, as long as your first- or second-choice treating doctor referred you to the specialist—who may then refer you to other providers (in what Illinois law calls the “chain of referrals” from the treating doctor).
When the insurance company uses a PPP, the specialist should generally be in the network. However, you should be allowed to use a non-network specialist if there isn’t someone in the network who can provide the treatment you need—as long as you follow the PPP’s rules for getting authorization ahead of time.
The insurance company may request what’s known as a “utilization review” when it objects to expensive treatment recommended by your doctor. As part of this process, a medical professional will review your medical records, including reports from your doctor. If the reviewer decides the treatment isn’t appropriate, the insurance company won’t have to pay for it—unless you’re able to prove otherwise.
If you’ve having trouble getting the medical care you need for a work injury, you should seriously consider speaking with a lawyer. An attorney with expertise in workers’ comp can help you navigate the complicated workers’ comp system in Illinois, challenge a utilization review decision or doctor’s report, and receive all the benefits you deserve.