Establishing and Changing Primary Care Doctors in Workers’ Comp

A common method to control costs in workers’ compensation claims is the designation of a primary treating medical provider. This is important for a number of reasons and is something claim handlers need to understand. Failure to recognize its significance can result in excessive costs in the claim management process.

Threshold Issues to Consider for Primary Care Doctors in Work Comp

Determinations regarding the establishment of a primary care doctor are usually defined by statute or administrative rule under a jurisdiction’s workers’ compensation law. In many instances and employee establishes their primary doctor based upon the number of times or frequency an injured employee receives medical care and treatment following an injury.

Time to Consider a Change in Healthcare Providers?

A health care provider is typically considered the “primary doctor” once they direct and coordinates the course of medical care provided to the employee. Employees are usually allowed to only have one primary health care provider at a time. Once an employee establishes a primary treating physician, their ability to change that provider are limited. Circumstances that permit change without initiating a legal process include the following:

• Death or retirement of a physician, doctor or other health care provider;

• Termination or suspension of a provider’s health care practice; or

• Referral from the primary provider to another provider.

Failure of an employee to receive advance approval of a change in health care provider can have a significant impact on a workers’ compensation claim. One common consequence of this action is the ability of the workers’ compensation insurer to avoid legal liability for medical care and treatment received by the employee even if the medical care is reasonable, necessary and causally related to the work injury.

Other Factors to Consider When a Request for Change Occurs

If a change is not approved by a workers’ compensation insurer, employee’s generally have the ability to initiate a legal process to change their primary health care provider. While factors to consider in this process vary, they generally include the following issues:

• Whether the requested change is an attempt to block reasonable treatment or avoid acting on the provider’s opinion concerning the employee’s ability to return to work: A change is sometimes requested when an injured employee is hesitant about proposed medical care and treatment. Failure to follow the proposed treatment plan can also delay recovery.

• Development of a litigation strategy rather than to pursue appropriate diagnosis and treatment: This can occur in instances where an employee is malingering or exhibits unsafe habits such as seeking opioid-based prescription medications.

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• The provider lacks expertise to treat the employee for the injury: Medicine is complex. Sometimes a medical provider may lack the necessary training or experience to properly care for an injured employee. There are also health care providers known to enable an employee by seeking excessive care or unnecessary procedures.

• Other factors to consider: It is important to evaluate a request for change in a health care provider in terms of travel costs to see a particular health care provider and other unnecessary expenses. Members of the claim management team should be skeptical of a request for change when it is certain the employee does not require additional care.

Members of the claim management team also need to consider the best interests of all parties. What these means is often vague and uncertain. This requires the application of the “smell test” to determine if such change is really necessary.

Conclusions

Claim handlers need to be vigilant of excessive medical costs as long as it continues to drive workers’ compensation program costs. One area of focus should be a determination on the employee’s primary medical provider following a work injury and what circumstances truly necessitate a change.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a 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 & lead trainer of Amaxx Workers’ Comp Training Center .

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.