Doctor Choice in Workers' Compensation


This is a question that arises often in workers' compensation cases, and is often one that has people the most confused and frustrated.

The short answer is "yes." Under the Illinois Workers' Compensation Act, an injured worker is entitled to choose two health care providers or referrals therefrom. If you get injured at work, you can pick any doctor you wish to treat your injury. This means that if you see your primary care physician, who refers you to an orthopaedic doctor, who refers you for an MRI, and then sends you for physical therapy, it all counts as only one of your two choices.There is a bit of a wrinkle here, however, in that IF your employer has established its own PPO network, you are limited to one of those providers and then are left with only one of your own doctor choices to utilize. This is a relatively new change that was incorporated in the Workers' Compensation "reform" law enacted and signed in late June of 2011.

Most employers have not established PPO networks that are strictly for workers' compensation. Do not be confused by the fact that your company may offer health insurance with a PPO option, as this does not satisfy the requirement of a separate PPO for workers' compensation only that the law requires. Unless your employer has a PPO specifically devoted to workers' comp, you have the "two doctor" choice available to you.

There can be some complexity added to all of this if you, the injured employee, decides to avoid the "company doctor" under the WC PPO and opt for your own doctor instead. If you do that, your rejection of the PPO doctor counts as one of your two choices, and you now are left with only one doctor or those referrals.

But Don't I have to Go to the Company Doctor First?

No. There is no such requirement, although many employers act as if there were.

Keep in mind, many workers are injured in a workplace setting where they are rather powerless to decide where they want to go. When you fall and break a leg, cut your hand, or throw out your back, you generally are in pain and not exactly thinking clearly or reviewing your rights under workers' compensation. Thus, it is very common for employers to offer to drive you to a clinic, which, just so happens to be where they take all the people injured at work and, which just so happens to enjoy the fact that it gains a steady stream of patients from that jobsite. Perhaps I am a bit cynical, but it sure seems that facility would be a bit "motivated" to return injured workers to work a bit quicker than a doctor who was less interested in receiving repeat business. It certainly seems that way from the 23 plus years that I have practiced in this area that oftentimes these company clinics can derail a workers' comp case right from the start.

The lesson is to remember that YOU HAVE A CHOICE TO SEE A DOCTOR OF YOUR OWN CHOICE.

Why should it matter which doctor you see if you are injured at work?

It shouldn't, but in reality it does, and a "doctor battle" is often the tipping point of many workers' comp cases.

A very common scenario is when an injured worker is taken to the "company clinic," where the friendly doctor finds that the employee has a mild back strain and can return to work with no treatment within days. Weeks later, the employee is still in pain and contacts a lawyer. The lawyer suggests the employee find a doctor with some expertise in back injuries, and, not surprisingly, that doctor orders the worker off work. If the worker heeds his or her own doctor's orders, he or she may be fired by the employer, based upon the fiction that he or she was "released for work without restrictions" by the "company doctor." Once the worker is behind this wall, it is often hard to resuscitate his workers' compensation case.

Similarly, another common situation occurs when the employee does see his or her own physician immediately, who might order rest, time off work, and therapy. At some point, the employer has a right, under Section 12 of the Act (often erroneously referred to as "Independent Medical Exams," or IMEs), to have a doctor of its own choice examine the worker. Often, this doctor will disagree with the first doctor.

Think of how an arbitrator deciding these cases would view this situation differently from the first scenario. In the first case, the first person to treat the patient said he was fine while the second one found a more serious injury. If you assume the injured worker was doctor shopping so he or she could take off work (and potentially get paid some money under WC), then you might view the first doctor as more credible. While this may not be true, it is often hard to "undo" that which has already been done.

Why All Doctors Are Not Free of Bias in Workers' Compensation

I would love to report that all doctors are completely free of bias in all situations, and, for the great majority of doctors and health care providers, I would be absolutely correct.

There is, unfortunately, some inherent bias that comes with the territory, as alluded to above in talking about the "company clinic." Stated simply, a provider who gets all the injured workers brought to its doors from a particular company, or who receives a great deal of Section 12 work from a particular insurance carrier or workplace, might just work a bit harder to find a patient ready to return to work. Or, more starkly, that doctor may opine that surgery is not necessary whereas the worker's own doctor has already recommended such intervention.

Similarly, there is no denying that some "WC mills" exist, where injured workers are shuffled through possibly unnecessary treatment, with bills to be paid by the WC insurance carrier. Often, arbitrators find the opinions of physicians at these clinics as unreliable as those from the "employer's doctor."

The best choice for a worker is to choose someone reputable with experience in this type of injury. It is never a bad idea to have a few names chosen in advance for that "just in case" scenario.

What You Can and Should Do

Every worker injured while working (and, as stated in past blogs, this does NOT need to be the typical industrial injury) owes him-or herself the favor of knowing in advance what doctor choices he or she has, and, perhaps even keeping that information handy.

The simple fact is that if you are hurt while working, your best choice is to see a health care provider who is competent in treating the type of injury you have, and who is not seen as biased to either employers or employees. Knowing the possible negative repercussions of choosing the wrong doctor, or, not choosing your own doctor at all, is invaluable.

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