Work Injuries Medical Treatment: Preferred Providers and Independent Medical Examinations

A critical first step in any Boston workers’ compensation claim is immediate medical attention. When the injury is critical and the situation urgent, that means simply getting to the nearest hospital or another treatment facility.

Injured workers need to know they have the right to choose their own doctor as they continue recovery. However, you may soon become familiar with the terms “preferred provider” and “independent medical examination.”

Attorneys with the Jeffrey Glassman Injury Lawyers can explain that “preferred” doesn’t mean the one YOU prefer, and “independent” doesn’t mean “impartial.”

Most people don’t fully understand their obligations or rights under these provisions. But one’s course of action in meeting with these doctors can have a major impact on the future bid to obtain workers’ compensation benefits.

The information provided here may serve as a general guide, but it’s recommended that workers who are injured or sickened at work seek legal counsel as soon as possible in order to ensure your rights are protected.

While workers injured on-the-job in Massachusetts are entitled to seek treatment from their own doctor, they may be required to see one of their employer’s “preferred providers” for the very first visit following an incident or injury.

Workers’ compensation preferred provider arrangements are established in 211 CMR 51.00 and MGL ch. 176I.

In an emergency, you go wherever the first available or closest emergency care center is located. However, in non-emergencies, employers with existing preferred provider plans can direct workers to go to a particular hospital, clinic or doctor. You must do this for the FIRST SCHEDULED VISIT, or else risk your medical bills and lost wages not being paid by workers’ compensation.

It is simply not worth the risk to fail to abide by this provision. Keep in mind, however, that the preferred provider physician is paid for by your employer’s insurance company. That means there may be a potential bias and skepticism with your claims. If the doctor deems you not credible or doubts the cause of your injury, it could hurt your claim later.

During these visits:

• Tell the physician your injury was work-related, and explain exactly what happened.
• Don’t exaggerate. This pertains to both the injury/illness and the nature of the accident.
• Answer questions honestly, but don’t provide more information than necessary.
• Take notes. Be clear about any recommended treatments, medications and restrictions. Failure to abide by these terms could jeopardize your chances of having your expenses fully covered by workers’ compensation.

Your doctor will be an integral part of the workers’ compensation process, and to ensuring you receive benefits. That means it’s imperative that you receive an accurate diagnosis, and that your physician understands your job-related duties and how it resulted in or aggravated your condition.

Although your employer can require you to see a preferred provider for the first scheduled visit, you have the right to go to your own doctor after that.

The physician you choose is key because this will be the individual who provides direction on your course of care, and will make a determination on any work-related duty restrictions and the time at which you are well enough to return to work.

You have the right to switch doctors if you so choose. However, you can only do so one time without permission from the insurance company providing the worker’s compensation. After that, you have to first ask the insurance company for permission. If the insurance company refuses to allow you to see another doctor, your medical bills won’t be covered by workers’ compensation if you choose to go anyway.

Keep in mind that any personal information you reveal to this doctor will be noted in your health records, and those will be viewable by your employer. Make sure to ask your doctor for a copy of the report from your visit so you have that for your own records.

In some cases, the insurance carrier may raise a dispute over your doctor’s recommended treatments and costs. A skilled workers’ compensation attorney can help negotiate these disputes for you so you can focus on your recovery.

Once a worker undergoes an exam by his or her own doctor, the workers’ compensation insurance carrier is allowed to order an “Independent Medical Exam.”

This is not someone who will provide treatment to the worker. Rather, it is a doctor who will conduct a medical exam on behalf of the insurance company to make a determination as to the causation and extent of a worker’s injury.

It’s a one-time deal (usually), but it can be damaging to the worker’s claim for benefits because, despite the moniker, these exams are not actually “independent.” Doctors are hired by the insurance company, which means their reports are usually skewed in favor of a position that benefits the insurer’s bottom line. Workers’ injuries are minimized or dismissed, and their assertions of pain and other elements of the case are discredited.

A 2004 study published in the International Journal of Occupational and Environmental Health revealed there is a large discrepancy in opinions between the treating physician and the independent medical examiner opinions in work injury cases. In each situation, both doctors weighed:

• Diagnosis
• Work-relatedness
• Treatment recommendations
• Disability assessments

In only one of those 23 cases did the treating physician and independent medical examiner agree on all four aspects. On the whole, independent medical examiners made fewer diagnoses, determined fewer illnesses were work-related, made fewer treatment recommendations and assessed lower levels of disability.

Many of these doctors derive their payroll almost exclusively from the insurance company. They may not want to let go of such a lucrative deal.

Dishonest independent medical examination reports can be devastating for a worker’s case. Our attorneys work tirelessly to fight these damaging assertions. We know hearing officers and judges weight the testimony of each expert witness, and we have extensive experience in helping to devalue testimony that hurts your case.

Contact Jeffrey Glassman Injury Lawyers today for a free and confidential consultation.