The vast majority of people are comfortable with their primary care physician. After all, that is why they have this particular doctor to begin with. People may have a long relationship with this doctor, and overall they trust what they tell them to do for treatment.
But when you deal with an insurance injury claim, chances are that you will not be treating with this doctor in the beginning, or even at all. The injured party will be treating with the occupational clinic physician, and be referred to specialists within that particular network if the injury is more than a common strain.
Adjusters may have a lot of experience working with certain doctor networks based on their work in dealing with claims. These doctors are usually more that sufficient, but at times the adjuster has to be careful. There are certain doctors out there that see an insurance claim as a way to bill for a lot of unnecessary services. In this industry we hope that this would not be the case, but the reality is that this will eventually happen. Below we discuss some signs that may indicate it is time to direct medical care elsewhere:
1) The Current Doctor Wants to Keep All Treatment “In-House”
Larger physician networks will have large treatment clinics, where there are general medicine doctors, diagnostic services, physical therapy, and medication fill services. One thing to watch for is if this doctor wants everything to be at the same place. They will attempt to sell this as a “one stop shop” and preach the ease of services all within the same roof.
Most times if the injury is not severe, this is probably OK. If all an injured party needs is a short course of physician therapy and some X-Rays, then fine. But, if months have went by and the injured person is not seeing results, it is time to get them seen by another physician. The medical network wants to keep all of these services in-house because this maximizes their profit. But if they are not effective, it is time to move on.
2) The Treating Doctor is Not Listening to the Patient
People have a certain perception of a doctor. This is a person in a white coat that is supposed to help them feel better. They are supposed to listen to the complaints of pain, and come up with a way to correct these issues. If your claimant starts to voice that the doctor not listening to them, or not paying attention at all during the visit, this is a red flag. Especially if only a few minutes is spent with the injured party in the exam room. If the only opinion the treating doctor has after 3 months is to “Continue with therapy and come back in another month” then it is time to see a new doctor. After a month or two, an injured person should be seeing some tangible progress with their injury.
3) The Adjuster is Not Receiving Medical Records
A roadblock in claims is the lack of medical records. The availability of medical records is a necessity in the claims’ world. If these records are not sent timely, or if they lack any real substance, then you have to move away from continuing to use this doctor. A few sentences will not qualify as a detailed medial record of a medical examination. Doctors will have their own style of dictation, but failing to have quality medical records is a big no-no.
4) It is Difficult to Schedule an Appointment to See a Physician, but Easy to See the Physician Assistant (PA) or a Nurse Practitioner (NP)
A lot of insurance professionals will demand that their injured party be seen by the medical doctor on staff, and not by a PA or NP. Some clinics will start off with the injured worker seeing the doctor, but later on they will only see the PA or NP. It is not that the NP or PA doesn’t know what they are talking about; it is more about trying to provide the best care possible for the claimant.
Another red flag is if it takes a month to see the doctor. If the doctor is too busy to see the patient, then how can he really dig in and try to solve this case? Patients want to get used to seeing the same person time after time, so they know the doctor is actually tracking their progress or complaints. If you are going to the clinic and you are always seeing a different person, it creates distrust. That is not going to help the claim in any aspect, especially if the patient feels disconnected from the people providing the care.
5) The Treating Doctor Fails to Release the Claimant from Medical Care
The bottom line is the doctor has is to get this person feeling better and released from care. Depending on the injury, even if a person does not have medical restrictions, physicians will continue to schedule appointments to see the patient to “Make sure everything is going OK.”
Again depending on the injury, a follow up appointment is not against the norm. But if the injury is minor, and the doctor keeps trying to see the patient, then the adjuster has to step in and question this course of action. The culprit generally is the doctor trying to squeeze in a few more office visits so they can bill more to the insurance carrier.
Summary
Most clinics and physicians have good intentions. Unfortunately, this is not the case with all of them in the insurance world. By being watchful of what is going on, and by listening to what the claimant is relaying back to you, you can be proactive in managing the care for your claimant. In the end, it streamlines the process, and moves claims on to an eventual close.
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 is 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 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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