Every state requires the employer to provide the employee with full professional medical care, medicinal needs, eye glasses, dental needs, and prosthetic devises to recover from a workers compensation injury. Some jurisdictions accept acupuncture, chiropractic care, and other bodily treatments.
There are four medical care programs in practice. They are Full Control by the employer, Partial or Limited Control, a Combination through Medical Panels and lastly Employee Free Choice. In all instances the employer needs to be certain that the employee is made aware of which program applies to them. The employer has the obligation to inform the employee of all rights and duties imposed for both the employer and employee.
- Full Control Program: The employer choses the doctors and all medical providers necessary, and may even choose the pharmacy. They can make arrangements with medical management vendors.
- Partial Control Program: The employer choses the doctor and medical suppliers for a specific period of time allotted by the various state compensation laws, rules or regulations. The employee may choose to stay with those providers or seek their own providers at the end of the employer’s control period.
- Medical Panel Program. In this instance, a list of approved medical practitioners may be provided by the jurisdiction. The employer and employee then agree on which providers to use for the best recovery potential. (This program is mostly practiced in monopolistic jurisdictions where the state actually handles and pays the claims).
In the event of petitions or challenges by the employer or employee in the other three existing programs, the judge or referee may assign or advise both to use another medical provider.
- Employee Free Choice Program: Here the employee may go to whomever they choose for medical care.
Informing the Employee:
Informing the employee of the program applicable is usually done through an employee brochure, employment hand books, bulletin board postings, or an instructional sheet at the time of injury. It may be necessary to give written notification to family or other responsible parties when the employee’s injuries are such that they cannot act in their own capacity at the time of injury.
All instructions should be stated in clear understandable language, be in writing, and have some acknowledgement from the employee, and/or the family or responsible person, that the instructions are understood and accepted.
Duties and Rights of Employer and Employee:
Under employer control the employee will be entitled to obtain a second opinion if he is not satisfied with treatment. The employee may request a formal ruling by a compensation judge or referee to change medical providers. However, the burden is on the employee to show medical care is inadequate.
When an employer fails to inform the employee of their rights, uses unqualified providers, or neglects to enforce its obligation under full control, the employee may have the right to seek their own care and the employer could be estopped from trying to regain control.
Partial Control allows the employer to control the medical care for specified period of time by compensation law or regulation. The employer chooses and posts a list of doctors. The listed doctors need to be able to care for the employee’s injury or have the employer’s approval to send the employee to a specialist. The employee is obligated to choose one of the posted doctors after the injury occurs. When the employee does not recover with in usually accepted recovery periods, or the stated time period elapses, the employee may have the right to choose a personal medical provider. Usually this allowed only once.
In the event the employer feels the employee’s provider is not acceptable, it may petition to the compensation board for another doctor. The employer will need a current independent medical examination with conclusive opinion to sustain its position.
The employee will be required to attend the employer’s independent medical exam. The employer may be allowed to suspend medical care payments and/or weekly benefit payments until compliance. All this should be done timely, in writing, and telephonically to all parties concerned. All these items need to be documented in the employer’s records.
The employee will also need medical reports to sustain their position.
Employee Free Choice allows an employee to choose their own medical provider. The employer must allow the employee to use the chosen provider.
The employer may challenge the use of the employee’s provider if it can conclusively establish that the provider is either not qualified, or demonstrates that it is not acting in the best interest to return the employee to duty.
Challenging the employee’s medical provider requires an employer to obtain an independent medical examination and opinion to sustain its position. The employee is required to attend the employer’s independent examination. Benefits and medical bill payments may be allowed to be suspended if the employee refuses to be compliant in attending the independent medical examination. It is imperative that all notices be timely, in writing, and documented in the employer’s records.
Some jurisdictions require that the employee upon being hired by the employer must give the employer the designated medical provider to be used in the event of an injury. The employee’s failure to do this may result in the employee not being allowed to use that provider
Stay Current. Changes in workers compensation medical provision occur daily due to legislative action, judicial decision, rule and regulation change, technical advancement and social practice. This makes staying current a challenge. Constant review of the program is necessary.
Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a monthly basis working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: [email protected].
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.
