If your Texas employer has workers’ comp insurance, you have the right to health care that’s reasonable and necessary to treat your work-related injury or illness. This includes doctors’ appointments and exams, surgery, hospitalizations, prescriptions, physical therapy, and medical devices. Once you report your injury and file a Texas worker’s comp claim, you need to select a doctor who will direct and approve all of your medical care (except for emergency treatment).
Your treating doctor will play a crucial role in your workers’ comp case—affecting your recovery as well as how much you’ll receive in Texas workers’ comp benefits. Among other things, the treating doctor will:
Because of the treating doctor’s role, your choice of physician will be one of the most important decisions you make in your workers’ comp case. So how do you choose a doctor?
If your employer’s insurance company has a contract with a workers’ comp health care network, you’ll have to select a doctor within that network. Your employer must be upfront about these requirements. If you were already seeing a primary care physician from your employer-provided HMO before the injury, you can choose that physician as your treating doctor for your workers’ comp case.
Your employer must give you a written description of the terms and conditions of the health care covered through workers’ compensation. If you don’t select a doctor within 14 days of receiving this information, the insurance company may choose the treating doctor for you.
Different rules apply if there isn’t a network contract. In that case, you may select any doctor who’s approved by the Texas Division of Workers’ Compensation (DWC). (Check the list of health care providers who aren’t approved for treating workers’ comp patients in Texas. You can can also search for a doctor on the DWC website; choose "locate doctor" under the main menu.)
Sometimes the initial doctor doesn’t work out. Maybe the doctor-patient relationship is strained, or you believe the doctor is more concerned with your employer’s financial interests than your treatment. Maybe you don’t think the doctor is giving you the right kind of treatment needed to recover. You may be able to choose a new treating doctor, but you have to follow the appropriate rules.
If there’s a health care network, you need permission from the insurance company before you can choose a new treating doctor from the network’s list of approved physicians. (Check with your employer for the specific rules and requirements.) You can appeal if your request is denied.
If network rules don’t apply, you may send DWC a written request to change the treating doctor, including information about your new choice and the reason for your request. You can make this request by telephone if the change needs to happen immediately for medical reasons. DWC will decide if you have a valid reason for switching doctors. It won’t approve your request if you just want a different medical report or opinion about your permanent limitations. You can appeal if the request is denied.
You might need medical treatment that your treating doctor can’t provide, like physical therapy or surgery that’s not in the doctor’s area of expertise. If it’s medically reasonable and necessary, your treating doctor may refer you to a specialist, even if the specialist is out of network.
Health care networks must let injured employees with chronic, life-threatening injuries or chronic pain apply to use specialists as their treating doctors, as long as the specialists are in the network.
You or the insurance company may disagree with your treating doctor’s opinion about different medical issues, including whether your injury is work related, the extent of your injury, whether you can go back to work, and your permanent limitations. When that happens, you may request a “designated doctor examination” (often called an independent medical examination in other states) to give an objective opinion about the dispute. The insurance company may also request the exam, or DWC may order one on its own. Either way, DWC will select the designated doctor to perform the exam.
If you have a medical dispute with the insurance company, or you’re having problems with your doctor, you should strongly consider speaking with a lawyer. A qualified workers’ comp attorney can help you switch treating doctors, challenge the designated doctor’s report, and get the medical care and benefits you need.