Often times in workers comp cases, injured workers will go treat with a primary care physician, even if that is technically not allowed. This is due to the fact that there is a negative stereotype attached to “clinic doctors” or what many workers call “the workers comp doctor.” Contrary to popular belief, these doctors do not work for the insurance carrier. Sure, these physicians may seem more aggressive than the primary care doctor, but that is for several reasons. The most important one is being that they have no vested financial interest in obtaining a comp case as a long-term patient. The old adage goes that “treating doctors get paid to treat”, and they like to keep the waiting rooms filled up day after day, and they do so by not being as aggressive as necessary.
So what if the injured worker is able to skirt around the system and run to a primary care doctor? Is the employer stuck with this doctor forever, and what can be done to keep the claim moving forward? How should one go about getting the information needed for the claim?
If this injured party has had prior treatment for this complaint with this doctor, be sure to request a copy of the chart and ask for all records.
Say this worker has had similar complaints of back pain in the past, and the records show that he did treat with this doctor in his past comp claims. This means that with a signed medical release, the doctor should grant access to these records, and any other records that pertain to back treatment. If this doctor has dictated notes, it can yield several clues of possible injury outside of the course and scope of employment. This of course is solid ground for a dispute on the case, since you the actual injury may not be related to the worker’s actual employment.
Also included in the notes will be objective evidence of what actually is wrong with this patient. If he has all subjective complaints, then that injury may not be as severe as the claimant is suggesting. The bottom line is gathering medical records can provide several medical clues as to what is happening and will only help the case.
How does this doctor relate this injury to the patient’s stated injury that arose out of employment?
The main key in any comp case is the causal relation statement. This is where the doctor takes the subjective and objective complaints and evidence, and ties them back to the worker’s employment. A lot of primary care docs that do not have a lot of comp experience will purposely be as vague as possible when it comes to this issue. A common statement a doctor will make is one similar to “The patient did not have any prior complaints of injury other than something happening at work; therefore, it must be work related.” This is not exactly true, since even though a person may be at work and have pain, it does not mean the work actually caused the pain or injury. Sure, work can contribute to this scenario, but the adjuster has to get to the ultimate cause. If a person has back pain, and there is a strain injury at work, it does not necessarily mean that the carrier has to pay for surgery that corrects degenerative conditions. Work may have exacerbated these pre-existing medical conditions, but it is a stretch to say that work actually caused the arthritis. It is possible is a few circumstances, but overall the common result is admitting that work caused a temporary exacerbation of a pre-existing condition.
If performing an IME or Peer Review that disagrees with the treating doctor’s causal relation, and the treating doctor disagrees with the IME doctor, how is that primary care doctor addressing this issue and what evidence are they using to solidify the opinion?
The second most common scenario is an IME doctor disagreeing with the primary care doctor’s opinion of causal relation. This is when claims will head into litigation, since there is a medical dispute about the origin of the injury. We have seen a lot of treating doctors say they disagree with the IME doctor, but then they do not elaborate. If this is the case, the adjuster will almost always side with the IME doctor, terminating medical coverage for this injured worker. In the occasion that the treating doctor makes an argument but still disagrees with the IME doctor, they may agree to disagree. Again this helps the adjuster, because that adjuster will side with the IME doctor, and overall it will take a Magistrate to make the final opinion on which doctor they find more credible. As the doctors are going back and forth arguing about who is correct, try to see what the treating doctor is using as the basis for the opinions. It should be objective medical evidence, and not based on subjective complaints. If it’s all subjective complaints, then that will only strengthen a suspension.
Is the treating doctor providing medical slips and records on a timely basis to support the worker being disabled?
If the answer to this question is yes, then the adjuster must dig deep to find evidence contrary to what the doctor is opining. This can be in the form of prior injuries, auto accidents, surgical records, etc. Try to find good solid evidence that the treating doctor does not know about, then submit it and ask if the opinion changes.
If the treating doctor is not supplying the necessary documentation needed, then there are grounds to suspend treatment with this doctor until the documentation required is received to make a decision on the ongoing compensability of the claim. Most claimants will get frustrated if their treatment is suspended. Their doctor may be telling them the injury is work related, but there is no supporting documentation to draw that conclusion.
Use of covers letters and nurse case management
After all of the attempts to gather the information needed, there is still a dead end. So what to do now? One option is to draft a concise cover letter to the treating doctor outlining concerns. Doctors like to know what they have to address in comp cases. Every doctor has a unique style when it comes to these issues. The treating doctor may actually help a defense if you draft a neatly organized cover letter outlining the facts of the case with the questions concerning the compensability. Since the adjuster is not in the room when this patient is being seen, who knows what the worker is telling the doctor? Another way to confirm these facts is using an onsite nurse case manager. The nurse can talk to the doctor before and after the appointment, and can be very useful in getting the information needed pertaining to any medical documentation desired. The nurse may not be able to actually be present in the room during the exam, but talking to the doctor before and after the appointment may help connect the dots between what medical evidence is showing, and what the patient is actually complaining of in regards to the injury. Coming to these conclusions will only help the adjuster arrive to the proper decision on the compensability of the claim.
If the injured worker is treating with a primary care doctor not familiar with the comp system, be careful and thorough about gathering information. Be sure to put the time in on doing a detailed background investigation and pass that information on to the treating doctor, so they can see exactly what you are seeing. This will help them make the correct opinion on the overall compensability of the claim. If the attempts fail, utilize an IME and nurse case manager to help bridge the process. The adjuster can never have enough information when it comes to making the proper decision on claims.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: email@example.com.
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
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