Workers’ Comp Doctor Choice: Can I Select My Physician, or Can the Employer and Insurer Force Me to Go to Their Doctor?
The workers’ compensation insurance company wants to control your medical treatment to reduce its costs and the amount of the benefits you receive. However, you can choose your physician for an occupational injury from a list of doctors.
You know the importance of seeing a doctor after you get hurt at work.
But, if you are like many injured employees, you do not know which doctor to see for your occupational injury or whether your employer can force you to see a specific physician.
You likely found this page researching one of three situations:
- You reported the work injury, and your employer told you to go to its in-house occupational health clinic or a local urgent care center. However, you are concerned about this provider’s ability to treat your medical condition, or the recommendations received at your first appointment.
- Your employer or the insurance claim adjuster assigned to your case sent you a panel (list) of doctors and told you to choose one; otherwise, the insurer will not pay for treatment.
- You selected a treating doctor for the work injury and have received extensive treatment; however, your employer and insurer sent you a notice demanding that you attend an Independent Medical Evaluation (“IME”) with a doctor you have never heard of.
Whatever the reason, keep reading to learn more about the “choice of doctor” dispute that frequently arises in workers’ compensation cases.
Our hope is that you will have a better understanding of your right to choose a workers’ compensation doctor after reading this.
Then, if you have more questions about workers’ compensation law or want to talk to a top-ranked attorney, call us at (804) 251-1620 or (757) 810-5614.
We have negotiated high-value work injury settlements for hundreds of injured employees in your shoes. And we want to fight for you.
Does It Matter Who My Workers’ Comp Doctor Is?
The doctor you choose to treat your work injury has a crucial role in your health and your workers’ compensation case.
First, you want a workers’ compensation doctor with expertise in treating your injury. The goal is to heal, return to as close to your pre-injury condition as possible, and return to the workforce. The better your workers’ comp doctor, the more likely these things will happen.
Second, your treating physician usually determines:
- What medical treatment is reasonable and necessary for the injury or occupational disease.
- Whether you have medical work restrictions (total disability or light-duty restrictions) that prevent you from returning to the workforce or your pre-injury employment (in turn, these restrictions determine your eligibility for wage loss benefits, such as temporary total disability (TTD) or temporary partial disability (TPD)).
- When you have reached maximum medical improvement (MMI) for your injuries (in turn, this determines your eligibility for permanent partial disability (PPD) payments under workers’ comp); and,
Indeed, the case law in some courts (including Virginia) says the Workers’ Compensation Commission (the judge) must give great weight to the treating physician’s opinions on this issue unless certain exceptions exist.
Therefore, who you choose as workers’ comp doctor affects your health and the amount of money you receive.
How Do States Decide the Doctor Choice Issue in Workers’ Compensation?
The patchwork of state statutes and case law deciding physician choice disputes in workers’ comp tries to resolve two ideals.
First, society and the law recognize that adults can make medical decisions themselves. Indeed, only a court order can take this right away.
This value encourages states to allow injured employees to choose their doctor after a workplace accident and to receive treatment from someone they trust.
Second, the workers’ compensation system wants to ensure that injured employees receive the proper treatment for their injury or illness.
Allowing employees to choose any workers’ comp doctor without insurance company input could lead to incorrect treatment that prolongs disability duration.
Therefore, state laws on workers’ comp doctor choice weigh these values. Some states permit you to choose whatever workers’ compensation doctor you want. Other states, however, limit your choices.
The Workers’ Compensation Insurer’s Level of Control Over Doctor Choice Depends on Whether the Physician Will Treat You or Perform a One-Time Evaluation for the Defense.
Any given doctor in your workers’ compensation case has one of three roles:
- Treating physician – the doctor providing treatment for your work injury
- IME doctor – the physician hired by the insurance carrier because it questions the causal relationship between your work injury and the treatment or whether the medical attention is reasonable or necessary. Usually the IME report is unfavorable to your case, so we call it what it is in our written briefs – a defense medical evaluation.
- Second opinion physician – the doctor your treating physician refers you to for a second opinion or that you see on your own before deciding the next steps for treatment.
Whether the insurer can force you to see a specific doctor for the work accident depends on which of these roles the doctor will have.
Can I Pick the Treating Doctor for My Workers’ Compensation Case?
In Virginia (and many other states), you can choose your workers’ compensation treating physician. Your employer or the insurance adjuster cannot force you to see a specific doctor.
However, your selection rights are not infinite. Employers and insurers can limit your options to some extent.
Your employer should give you a panel of physicians when you report a work injury or the diagnosis of an occupational illness. This panel lists doctors’ names, as well as their addresses and telephone numbers.
You can choose one of the doctors on this list to provide medical attention for the work injury. With some exceptions, this physician becomes your authorized treating physician for the entire workers’ comp case.
Once this person becomes your treating workers’ compensation doctor, your employer and its insurer must pay for the following:
- Charges billed by your authorized treating physician for reasonable and necessary medical treatment, including surgery.
- Charges billed by any medical provider to whom your authorized treating physician refers you
- Orders for diagnostic imaging, medication, functional capacity evaluations (FCEs), physical therapy, work hardening, and palliative treatment (such as acupuncture, chiropractic care, and even medical cannabis)
Can I Choose Which Doctors are on the Employer’s Workers’ Compensation Panel of Physicians?
No.
The Workers’ Compensation Act permits the employer to choose which doctors are on its panel of physicians, subject to specific rules. You and your attorney have zero input on the makeup of the workers’ compensation doctor list.
However, you may suggest panel members to the claim adjuster or the insurance defense attorney. The insurer may listen to these suggestions if you live in a rural part of the state with limited physician choices or have moved out of state and the adjuster is unfamiliar with doctors practicing near your new residence.
What Happens if I Refuse to Treat with a Doctor on the Workers’ Compensation Panel of Physicians?
We want the Virginia Workers’ Compensation Act and all state workers’ compensation systems to follow the Longshore and Harbor Workers’ Compensation Act (LHWCA) system, which allows injured longshoremen to choose their doctors.
The freedom to select a workers’ comp doctor you have researched and are comfortable with can improve your healing and recovery, furthering one of workers’ compensation’s purposes.
Unfortunately, the law does not give you that flexibility. If the insurer provides a valid panel of workers’ comp physicians, but you refuse to pick and treat with one, there are consequences.
Specifically, the Commission (or your state’s workers’ comp board) may rule that the employer and insurer do not have to pay for charges from any non-panel physician.
In addition, you may suffer stiff penalties if you have a Workers’ Compensation Award Letter but refuse to continue treating with the panel physician you have established care with, despite that doctor recommending continued treatment.
The employer may apply to stop your wage loss benefits because you are refusing to comply with medical treatment.
When Can I Choose a Workers’ Comp Doctor Who is Not on the Employer’s List?
Several scenarios may allow you to ignore the employer’s panel of physicians and choose a workers’ compensation doctor who is not on the list.
First, the insurance company may wait too long to offer a panel.
Generally, the sooner you receive medical attention, the better your opportunity to fully recover from the occupational injury.
If the insurer waits to offer a panel until you have established a course of medical treatment with a workers’ comp doctor, you may be able to continue treating with the non-panel physician.
Second, the insurance company’s panel could be invalid.
Check your state’s rules about the workers’ compensation doctors’ list.
In Virginia, for example, the panel must include the names of at least three doctors not members of the same medical practice. Otherwise, the workers’ comp panel is defective.
Further, the panel may include doctors who do not specialize in your injury or whose location prohibits you from seeing them. For example, the panel should consist of doctors 75 miles or less from you. Otherwise, it may be invalid.
A word of advice: do not assume the insurer’s panel is valid.
The number of defective physician panels has increased in the past few years. There are a few explanations for this. Mergers occur frequently in the health care industry, especially in orthopedic medicine, limiting the number of separate medical practices providing treatment to workers’ comp patients in a specific area. In addition, claim adjusters sometimes handle claims in multiple states. They need to become more familiar with the potential medical providers as adjusters who focus on Virginia (or wherever you may live).
Third, the insurer may offer a panel but fail to send authorization or payment to the doctor you choose from the list. If this happens repeatedly, you can select your workers’ compensation doctor without limitations
Fourth, the treating physician may prematurely terminate your care and release you to full duty, telling you they have nothing more to offer.
In this case, you can seek treatment from a doctor who was not on the panel. If this new physician disagrees with your initial treating doctor, you can file a claim with the Workers’ Compensation Commission, asking that the new doctor become your workers’ comp doctor.
For example, we have obtained workers’ compensation settlements for many injured employees whose initial doctors released them from care. Subsequent physicians, however, reviewed the Magnetic Resonance Imaging (MRI) and concluded that additional surgery (shoulder arthroscopy, spinal fusion, total knee replacement, etc.) was warranted.
You can learn how to change your treating physician in workers’ comp here.
Can Workers’ Comp Tell My Treating Doctor What Specialists, Therapists, or Other Health Care Professionals to Refer Me To?
No.
Although employers, insurers, and the nurse case managers they hire may try to exercise control over all facets of your medical treatment, workers’ comp laws do not permit them to dictate to your physician where they can refer you for specialized care. This level of control is called “medical management,” and it’s not allowed under case law interpreting the Workers’ Compensation Act.
For example, suppose you suffer head trauma in a forklift accident at work.
Initially you select an internal medicine doctor from the workers’ comp panel.
That doctor diagnoses a concussion and refers you to a specialist in post-concussion syndrome.
The workers’ comp insurer may tell you to see a different traumatic brain injury (TBI) specialist because the doctor you were referred to charges higher rates or is reputed to be claimant-friendly.
But the workers’ comp insurer cannot do this. It must honor your treating physician’s referrals.
Or, if your current workers’ compensation doctor does not refer you to a specific physician, the insurer must offer a panel of specialists to choose from.
Once you establish care with the specialist, this doctor becomes your new workers’ comp physician.
Remember: The authorized treating physician controls your medical treatment, not the insurance company. And the insurer must pay for referrals from your work comp doctor.
Can Workers’ Comp Force Me to See Their Doctor as the Treating Physician if I Do Not Receive a Panel?
No.
By failing to provide a list of doctors to choose from, the employer and insurer lose the right to limit your choice of treating workers’ comp doctors.
Instead, you can choose what doctor to see and then seek to hold the insurer responsible for unpaid medical bills or repaying Medicaid, Medicare, or your private health insurance if you used such coverage.
When Can the Workers’ Comp Insurance Carrier Force You to See a Specific Doctor?
Earlier in this article, we mentioned that a physician may serve as the IME doctor in a workers’ comp case.
In Virginia, the insurance company uses Code Section 65.2-607(A) to force you to attend an IME. Your state may have a similar statute or rule.
The IME is the only time the employer or insurer can force you to see a doctor. However, you may be able to refuse to attend the IME based on location, specialty, or lack of adequate notice. Further, your state’s regulations may allow you to take a witness to the IME appointment.
The rationale for this rule is that an IME is not medical treatment.
Instead, it is a one-time appointment where the doctor examines you (usually for less than fifteen minutes, although some neuropsychiatrists take longer) and reviews your records. Then, the doctor sends a report to the insurance company that paid for it.
Typically, the insurer schedules the IME because it does not like your treating workers’ comp doctor’s opinions on disability or treatment recommendations.
If you received an IME notice from the insurer, we recommend reading our article on what to expect at the workers’ comp IME appointment.
Get Help Choosing the Best Workers’ Comp Doctor for Your Injury
If your employer follows the law and provides a panel, there are limits on who you can choose as your workers’ comp doctor.
If, however, your employer fails to do what it should or denies your case, you have more freedom to pick your physician for the occupational injury or illness.
The rules governing the choice of physicians in workers’ comp are complex.
And the consequences of making a mistake can be devastating, leading to tens of thousands of dollars in medical provider bills you must pay for.
Don’t leave things to chance or hope.
Our workers’ comp attorneys can prevent the employer and insurer from forcing you to see a specific doctor when they do not have that right, help you select the best doctor for your injury, and navigate the many issues that arise in medical treatment for work injuries.
Call us at (804) 251-1620 or (757) 810-5614 to start.
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