Navigating the workers’ compensation medical process can add even more discomfort to a painful work injury. Massachusetts 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.