Navigating the workers’ compensation medical process can add even more discomfort to a painful work injury. Each state has its own rules and regulations regarding workers’ comp claims, but one rule is common to all: Injured workers seeking benefits must be evaluated and diagnosed by workers’ compensation doctors hired by the employer’s insurance company.
If you are injured on the job and making a workers’ comp claim, you must be medically evaluated and treated by doctors who are approved by your employer’s insurance company. Virtually all state regulations permit you to be treated by your own doctor, but your claim is highly dependent on the medical opinion of the doctor(s) you choose from the insurance company’s approved list.
Doctors have various reasons for deciding to work for an insurance company, but like most people in the workforce, their goal is a paycheck. Whether they are seeking to augment their private practices or are retired and need additional income, most are financially motivated. Doctors with certifications in surgery, orthopedics, or other specialties aren’t often found performing medical evaluations for workers’ comp insurance companies.
Depending on his situation, a doctor may count on the continuing income from workers’ comp referrals. If he disagrees too frequently with an insurance adjuster, the doctor may find himself off the approved list of doctors.
Some doctors primarily handling workers’ comp claims are often considered “fringe” doctors. Many don’t keep up with the latest medical literature, pursue continuing medical education, or stay current in the latest medical technology. Some are general practitioners with limited or no previous experience in orthopedic medicine.
The majority of workers’ comp claims involve torn cartilage, herniated disks, stretched muscles and tendons, and other soft tissue injuries. Back injuries are especially difficult to diagnose. Often determining the root cause of a patient’s back pain requires MRIs, CT Scans, and other expensive diagnostic tools.
Workers’ compensation doctors know insurance companies don’t like spending money on diagnostics. They are expensive and complicate the entire claim. The doctor may not tell you he would recommend those diagnostic or therapeutic services. Then he won’t have to deal with your frustration or become embroiled in a controversy with the insurance company.
As a result, a good number of insurance company approved doctors are more likely to treat injuries with pain medication. Pills are much less expensive than an MRI. Too often doctors don’t believe patients’ accounts of their pain and discomfort. To remain on the list for workers’ comp referrals, some doctors may classify patients as malingerers, rather than diagnosing real pain issues. That’s why second opinions are so valuable.
Independent Medical Examinations
Several circumstances may cause the insurance company to request that you submit to an Independent Medical Examination (IME):
- The insurance company disagrees with their doctors or with your private doctor.
- The claim is moving too slowly and/or costs are rising too quickly. (Workers’ comp insurance adjusters want to close claims as quickly and cheaply as possible.)
- Evidence is needed to resolve a controversy about the patients’ condition and right to benefits, to deny the claim, or to extremely limit the amount and type of treatment the injured worker receives.
There is no such thing as a true IME. Doctors hired to perform IMEs are usually paid by the same workers’ comp insurance company handling your claim. In most cases, the adjuster working your claim chooses the doctor you will be required to see. If requested by the insurance company, you must submit to an IME. Your refusal may allow the adjuster to deny your claim.
The role of the workers’ compensation doctor performing the IME is not to treat you. Her job is to study all the medical notes and documents related to your claim, discuss your injury, and examine you. The examinations are traditionally very short, some lasting less than ten minutes.
Most doctors who perform IMEs have little incentive to take the necessary time to study all the medical documentation related to your claim. Fees are based on the number of patients, not on the time spent on each case. Therefore, the more patients the doctor sees, the more money she is paid by the insurance company.
The Role of the Nurse Case Manager
Nurse case managers are registered nurses whose job is to facilitate communication between the doctor and the insurance company. You may have a nurse case manager assigned to help you with your claim. The nurse may present herself as your advocate who is acting in your best interests. Although most nurses are honest and hard-working, do not forget that she is employed by the insurance company.
She may ask to be in the room when the doctor is examining or treating you. You must understand that nurse case managers are bound to share their findings and impressions of you with the insurance company. Therefore, anything you say can be used against you.
In most states you can refuse to have the nurse in the examination room with you while you are seeing the doctor. In addition, you don’t have to speak with the nurse. Remember, it’s you against the insurance company, and the nurse case manager is just another of their employees.
Doctors with Financial Interest in Health Care Facilities
Another potential conflict of interest arises when doctors own or have financial connections in the health care facilities they are referring you to for diagnostic exams.
Because of their financial interests, doctors may order unnecessary or questionable tests hoping the insurance company will pay for them. Should the insurance company deem those tests medically unnecessary, you may be personally responsible for the costs of the tests or other extended treatment.
There are doctors who order tests because they truly believe it’s in your medical best interest to do so. These doctors put your health needs first without concern for who will later be responsible for paying. That may be the right thing to do, but when the insurance company later refuses to pay, you may have to bear the costs.
Most workers’ compensation doctors will seek approval for diagnostic tests (and extended treatment) from the insurance company before scheduling them. Even so, it’s a good idea to ask the doctor if the insurance has agreed to pay before submitting to any diagnostic tests.
Doctor Prescribed and Sold Medications
In some states, doctors can both prescribe and sell medications to their patients. A substantial number of workers’ comp insurance companies do not interfere when their approved doctors sell prescribed medications to patients at highly inflated prices.
According to a New York Times investigation, doctors can make tens of thousands of dollars each year selling medications to patients at a price as high as 10 times what they would pay at a local pharmacy for the same prescription. The newspaper cited an example of a doctor who sold thousands of Zantac pills for $3.25 each when a local pharmacy sold the same medication for $0.35.
Workers’ comp insurance companies reimburse the cost for medication they determine medically necessary, but refuse to pay if they find it unnecessary. Keep that in mind if a doctor writes you a prescription, then offers to fill it at the office. You could avoid a much higher out-of-pocket cost by driving down the road to your local pharmacy.
You should seek a second opinion if you feel the workers’ compensation doctor you chose isn’t addressing your medical issues. Most workers’ comp insurance companies permit an injured worker to have a second evaluation from another doctor on their approved list. While second opinions may seem helpful, the other doctors rendering those opinions are under the same conflict of interest as the primary one.
After a specified time, usually 30 days or more after filing your claim, you’ll be permitted to have an evaluation and treatment from a physician you choose, whether on the approved list or not. Getting a second (and sometimes third) medical opinion can help support your claim.
A second opinion isn’t always necessary. If you believe the primary doctor is addressing your medical issues and supports your claim, seeking additional medical opinions may be risky. You’re taking a chance that another medical opinion may not be as favorable, and a non-supportive opinion could damage your claim.
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Visitor Questions on Issues with Work Injury Claims
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I fractured my wrist and tore the TFCC (Triangular Fibrocartilage Complex) in 2013 and had surgery. I was released for full duty at work after physical therapy. I re-injured my wrist at work shortly after returning to full duty and filed for Workers’ Comp. I received an MRI that showed I had re-torn the TFCC.... Read More.
I fell from a ladder in October 2014. I was taken by coworkers immediately to the ER as I have previously had neck surgery in 1999 and was now in severe pain. They did a CT scan and said it looked okay. The ER doctor diagnosed me with “cervical strain and head trauma.” I was... Read More.
I have a workers’ comp case where I have a herniated disc and it was discovered in the MRI and X-Rays that I have a Spinal Disorder, but the attending physician states that I can return to work. He refuses to indicate that I have the Spinal Condition, which could cause me to have future... Read More.
My husband felt a sudden snap in his arm while working. He reported it to his supervisor, and requested to go see the company doctor. He went to the company doctor and they looked at his arm and said it looked like he had a torn bicep tendon. That Doctor sent him for an MRI... Read More.
On Jan 2nd 2015 I was battered by a patient of my employer. I was seen at the hospital and then told to go to a walk-in clinic on Saturday the 3rd. I did go but did not receive treatment, they just took a drug screen (it was negative, and I paid for it myself... Read More.
I was injured on the job, and was sent to a doctor by the adjuster. At the beginning I had transportation, but now my vehicle is in need of repairs and can’t be driven far. So the adjuster provided transportation. The doctor sent me back to work and the adjuster closed my case. Then she... Read More.
On October 2, 2012, I injured my shoulder on the job. In January 2014, I had a deposition for this shoulder, and then was referred to an IME (Independent Medical Evaluation). He confirmed this was a workers’ compensation injury, and now I am waiting for the workers’ comp insurance to give me a referral to... Read More.
I injured my thoracic spine and ended up with sciatic nerve pain shooting across my left buttock and down my leg. I was lifting a bag and twisted to put it in my back seat. I missed one day of work initially because I could barely get out of bed the next day. I went... Read More.
Three weeks ago I just had tendinitis, and my Dr. didn’t release me from work. I now have Carpal Tunnel and it hurts BAD, but yet, he still won’t release me because my employer can accommodate my modified instructions. I told the Dr. my other wrist was beginning to hurt and he adjusted the work... Read More.
My son in law’s father was at work in California. He was heading up some stairs and there were two identical clear glass doors at the top, one was usually open. However, this particular day both doors were closed; without any stickers, sign or caution tape on them, the doors appeared open. He ran straight... Read More.
I fell at work a year ago and I went to the doctor. They told me it was just a bad ankle sprain. As the year went by my ankle was still bothering me so I went back to the doctor. They finally did an MRI and found a lot of swelling, two bruised bones... Read More.
I slipped at work going down the stairs. I didn’t fall but in an effort not to fall, I twisted all of my weight onto one knee. As a result I have a small tear in my meniscus in my right knee. I have been seeing a Dr and physical therapist since then. The Dr... Read More.
I injured my back at work on August 13th, 2012. I waited about 2 hours with pain radiating down my leg into my feet, then I called our HR person as my supervisor was out of town. I reported the injury and went to a Care Now facility. Big Mistake! The doctor who saw me... Read More.
I wrecked a truck I used to drive while at work. I went to my own doctor who gave me a note to stay out of work due to my lower back pain I developed because of the wreck. He says I must not work until released. My employer refuses to accept my doctor’s note... Read More.
I injured my back at work (in Alabama) 3 weeks ago. The doctor kept me off work the first 2 1/2 days, then wrote for me to return to work with no restrictions as I am an office manager (clerical management position). Then after continuing to have severe pain, he referred me to an orthopedist... Read More.
I have my follow up appointment with my doctor this week as I have been signed off work since my injury. I recently accepted and signed a settlement with workers compensation, and just received a confirmation copy and notice from the WC attorney that it has been sent to the Board. I am now in... Read More.
I fell at work on the hallway carpet 9/24/2013. I was taken to the workmans comp clinic, X-rayed and told it was a sprain and that I could return to work the next day. I could not even dress myself the next morning and did not sleep all night. I went back to the clinic... Read More.
I am a maid, was injured at work when a wheel fell of my cart on 7/20/13. I was injured before in the same places (neck and lower back) in September 2005. On 7/26/2013 I saw my family doctor. X-rays were taken and medicine was given to reduce the inflamed area. I was no better... Read More.
I had a work related accident, hired a lawyer and the lawyer sent me to a clinic. In March the doctor sent me for MRI’s and after that they forgot about me. I’d been going to the doctors at the clinic regularly, each time complaining about the terrible pain I was in. Last month I... Read More.
I fell at work after returning from surgery and re-injured the same area. Workers Comp allowed me to see the attending surgeon for my right side and had me see their doctor for my left. If my surgeon says I can’t work until my arm shows improvement, and their doctor says I can return to... Read More.
My husband was hurt on the job in October of last year. He was placed on workers compensation. He saw an orthopedic doctor who released him on December 21st of last year. His employer has been trying to get paperwork from the 1st doctor so that my husband can go back to work… or that’s... Read More.
I was walking past the sink area at work and fell flat on my back. I left work and immediately went to the hospital, but a couple of days later my employers sent me to their worker’s comp doctor. The doctor never asked me to come back and when I called to try and get... Read More.
I injured my right shoulder on the job. My company has private insurance instead of Texas workman’s comp, but goes by the same rules if it’s to their advantage. I’ve had 2 surgeries and my shoulder still isn’t repaired. I could not get to a specialist doctor as they would not accept the insurance. I... Read More.
I was injured on the job. First the workers compensation doctor said I had no permanent impairment, then he listed permanent restrictions: no lifting, repetitive lifting or carrying anything over 10 lbs. Then the doctor said no maintenance care was required after my Maximum Medical Improvement (MMI), but he specified that I return from maintenance... Read More.
I was using an electric pallet jack and the machine surged backwards, pinning my upper arm next to a beam and piece of steel. The emergency button did not work and I was pinned approximately 8 minutes until someone found me, then an additional 3 or 4 minutes until the machine could be moved enough... Read More.
A base of a work basket was hit by another associate by mistake which moved the front end of the basket. I was walking past at the time and the basket caused me to trip and fall on my wrist. I went home in pain after filing an incident report and the next day went... Read More.
I had surgery 2 weeks ago for an open compound fracture to my pinky. I was told to see a specialist hand doctor in 2 weeks. The workers compensation provider has not found a follow up hand specialist for me to see, let alone gotten an appointment. What choices do I have? My hand is... Read More.
I was receiving workers compensation benefits and my doctor referred me to a pain specialist. The workers comp insurance carrier would not pay for the specialist and sent me to another doctor who got my benefits cut. I then was referred to the pain specialist who said I could not work. What is going on... Read More.
I injured my thumb at work. The doctors are recommending a fusion of one of the joints of my thumb, but I don’t want to do the surgery. Do I have a choice? What happens to my workers compensation benefits if I choose not to have the surgery? Read More.
I had back surgery three months ago, now it looks like I am going to have another surgery. My doctor ordered in-home support. Can my workers comp deny it? Read More.
In March of 2010 I had ulnar nerve surgery and shortly after that I had carpal tunnel surgery. This was all on my right arm and I’m right handed. I now have pain in my elbow. I’ve had to change the way I do many things because of the pain in my elbow. Workmans comp... Read More.
I have a questions about Workmans Compensation doctors. I have been to two different doctors and they both have different opinions. One doctor says I shouldn’t have surgery and the other says that surgery is needed. So I think the only way to know what to do is to get a third doctor’s opinion to... Read More.
I’m having workers comp problems with the doctor sending me back to work too soon. I was released by the MD to return to work, but I told him I wasn’t stable enough to come back to work yet. So upon returning back I fell for the second time on the job. I am so... Read More.