physician referrals in workers compensation

Physician Referrals in Workers Compensation

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In a workers compensation claim, an injured employee is generally authorized to treat with a primary care physician at a clinic selected by the Employer/Carrier as the initial treatment facility if the claim has been accepted as compensable. Throughout the life of a case, the law allows an injured employee to change an authorized physician only one time. However, an injured employee may treat with many different types of physicians if there have been referrals made to those physicians.

Every workers compensation case is unique in that there may be different body parts injured in the work accident and the severity of the injuries generally vary. In order for an injured employee to treat with a doctor that specializes in treatment for the specific injury or injuries suffered, a referral must be made by a prior authorized physician. For example, if an employee has injured his or her knee in a work accident, the primary care physician must make a referral to a knee specialist before the Employer/Carrier authorizes the specialist from within their network. Further, if the knee specialist believes the injured worker may need surgery, then a referral to a surgeon would likely be made. If the injured employee has suffered different injuries in the accident, for example to his or her back, neck, and shoulders, then referrals may be made for physicians that specialize in treatment of those specific injuries. In certain situations, the Employer/Carrier may authorize a physician that does not actually fall into the category of the referral that has been made. Having an attorney in this situation is advantageous since there are legal arguments which can be made to correct this error. If the Employer/Carrier does not agree to this, then the matter may be taken to a Hearing for a Judge to determine.

The advantage of having an attorney when a referral has been made is that an attorney will file a Petition for Benefits with the Court. Once a Petition for Benefits has been filed, there is pressure on the insurance company to set up the recommended physician within a certain period of time or they may be required to pay the attorney a fee. That is why it is important to hire a workers compensation attorney who handles these types of situations. If you were injured on the job or know of someone who was, have them give us a call at (844) 762-8155.