Who Chooses My Doctor When I File a Workers Compensation Case?

A Santa Rosa workers compensation lawyer can help injured workers get the medical care they need

Most people have a doctor they trust. Even if they don’t always visit the same doctor, people are often used to dealing with a particular clinic. It is understandable that employees who suffer work injuries want to be treated by a physician who has established a relationship with them and is familiar with their medical history.

Unfortunately, people injured who file a workers compensation case in California do not always have the option of receiving treatment from the physician or clinic of their choice. In limited cases, an injured worker may be allowed to predesignate a personal physician before a workplace injury occurs.

Medical Care

Medical care is one of the important benefits that injured workers receive in the workers compensation system. When a work-related injury occurs, the injured worker is entitled to have the employer, or its insurance company, pay for medical treatment she needs.

Medical bills are paid by the claims administrator. That’s why a work injury should always be reported as soon as possible after it occurs. It is also important to tell the doctor who treats the injury that the injury is work-related. The doctor’s office will send the bill to the claims administrator. Injured workers should not be billed for treatment related to a work injury.

The trade-off for that benefit is that the employer or its worker’s compensation insurance company, has “medical control.” That means they get to determine with whom the injured worker must treat for the injury. Of course, in emergency situations, injured workers should call 911 or obtain care from the nearest emergency room. An employer can designate a place to receive emergency care (such as stitches for a wound), but if the injury is life-threatening or if the employer is not providing prompt information about emergency care, the injured worker is free to get treatment from the nearest emergency facility.

In nonemergency situations, the claims administrator must authorize the treatment that is needed. The claims administrator has a limited time to authorize the care. Unfortunately, these time frames and not always followed.

An injured worker should receive a claim form promptly after reporting the injury to the employer. Filling out the form and returning it to the employer triggers the employer’s obligation to provide medical care. The claims administrator is required to authorize up to $10,000 in medical care costs during the first 90 days following the injury. Additional costs will be authorized later if the treatment the injured worker continues to receive is reasonable and necessary, and is obtained with a physician authorized by the claims administrator.

Most conventional care is covered in a workers compensation case. An injured worker who wants to obtain alternative care may need to pay for the treatment out of her own pocket, with the risk that she will not be reimbursed for those costs. Some alternative treatments, such as acupuncture, can be covered in the workers’ compensation system. It is best to check with the claims administrator or a Santa Rosa workers’ compensation lawyer if coverage is unclear.

Choosing a Doctor

Most employers (or their insurance companies) have created Medical Provider Networks (MPN), or groups of treating doctors who are preauthorized to treat injured workers. When the claims administrator authorizes an injured worker to obtain treatment, the administrator will provide the MPN list to the injured worker so he can select a doctor from the list.

The employer is also required to post a notice advising employees about where to treat initially for their injury after reporting a workers compensation claim.
If the employer has failed to post the notice, and if the employer does not offer medical treatment for the injury, an injured worker should seek treatment from his or her personal physician. The claims administrator will then be required to reimburse that doctor. If the claims administrator refuses to do so, a Santa Rosa workers’ compensation lawyer can help.

Changing a Doctor

An injured worker who is being treated by a doctor within the MPN can change to a different physician within the same MPN if they wish. An injured worker may be able to change treating physicians within the MPN more than once if there is a good reason for making the change. It is also possible for an injured worker to choose their own treating physicians, but only under very limited circumstances. To find out how, contact a Santa Rosa workers’ compensation attorney.

Getting Help

Employers are not always as helpful as they should be when an injured worker requires medical care for a workers’ compensation claim. To get advice in Santa Rosa about medical treatment for a workers’ compensation claim, call Kneisler & Schondel at (707) 542-5132. You can also ask us a question by submitting our online contact form.