Choosing and Changing the Treating Physician

Every substantive question in a compensation claim runs through a medical report: whether the injury is work-related, what the worker can do, when they have recovered as far as they will, and what permanent impairment remains. Whoever chooses the physician has enormous influence over all of it.

Three systems

Emergency care is available anywhere in every system — nobody is expected to check a network directory in an ambulance. The rules attach to ongoing treatment after the emergency ends, and that transition is where workers most often step outside the system without realizing it.

Why finding a willing physician is the real constraint

The rules on choice assume a supply of physicians willing to be chosen, and in much of the country that assumption is thin. Compensation medicine is paid under a state fee schedule, frequently at rates below what group health coverage pays for the same procedure, and it carries obligations no other patient generates: narrative reports on demand, impairment ratings, depositions, and correspondence with adjusters. Specialists decline the work for those reasons rather than clinical ones, which is why a worker in a rural county may have a statutory right to choose from a list of practices that are not accepting new compensation patients.

The billing consequences fall on the worker in a predictable way. Where the claim is accepted, the provider bills the insurer, and the worker is generally shielded from any balance — disputes about the amount go to a separate medical fee dispute process between provider and insurer, which the worker is not a party to. Where the claim is denied, or where the insurer accepts the injury but not the body part being treated, bills start arriving at the worker's address and are referred to collection agencies that have no knowledge of the claim.

The response is administrative rather than legal: send the provider the claim number, the insurer's name and the adjuster's contact in writing, ask for the account to be held pending the compensation dispute, and keep the correspondence. Paying the bill privately to stop the calls converts a provider's claim against the insurer into the worker's own reimbursement problem.

What the treating physician decides

Beyond treatment, the treating physician's reports typically determine:

• Causation — whether the condition arises from the employment.
• Work restrictions — what the worker can lift, carry, reach and sustain.
• Temporary disability status — whether the worker is off work, on modified duty, or released.
• Maximum medical improvement — the point at which the condition has stabilized, which ends temporary benefits.
• Permanent impairment — the rating that drives the value of the claim.

The declaration of maximum medical improvement is the pivot of the whole claim, because it converts an open-ended situation into a valuation exercise. Workers frequently do not realize it has happened until the temporary payments stop.

Getting restrictions written usefully

A release to work is not a medical fact so much as a comparison between capacity and job demands, and it goes wrong when the physician has never seen the job.

1. Ask for restrictions in physical terms: maximum weight, frequency, postures, standing and sitting tolerance, reaching, and any restriction on machinery or heights.
2. Provide a written description of your actual duties, including the parts nobody writes down.
3. Where the employer supplies a job description, read it before the appointment and correct it if it understates the demands.
4. Ask for a review appointment if the restrictions prove unworkable in the first week back.

Where a modified duty offer follows, whether it fits the restrictions is a factual question, and refusing an offer that does fit usually ends wage benefits.

Changing physicians

Nearly every system provides a route. Common forms: a one-time change on written request without cause; a change on showing cause such as a failure to treat or a breakdown in the relationship; a change within a network without cause; and a change by agreement with the insurer, which is frequently granted because a cooperative worker is cheaper than a disputed claim.

Two things to avoid: treating outside the applicable rules, which can leave the bills unpaid and the reports inadmissible; and changing repeatedly, which reads as opinion shopping to whoever decides the claim.

The mechanics are usually simple and usually mishandled. The request goes in writing to the insurer or the employer, names the proposed replacement, and states the ground where cause is required. Several states set a response period and treat silence as approval, so a dated copy of the request is what makes the deemed approval usable later. In network states the worker is entitled to the current directory rather than to whatever list the adjuster reads out, and the network's adequacy — whether it contains a physician of the necessary specialty within the prescribed travel distance who is accepting patients — is itself challengeable, which is often the faster argument where the directory is long and the availability is not.

The other physicians in the file

The treating physician is not the only medical voice. The insurer will commission its own examination, and that examination is adversarial in substance whatever it is called. Where treatment is denied rather than the injury disputed, the decision comes from a utilization review process that never sees the patient, and challenging it runs on its own procedure and its own deadlines.

Many states also provide for an agreed or neutral physician whose opinion carries greater weight on disputed questions, and where that mechanism exists it is frequently the most efficient way to resolve a medical disagreement without litigation.