Medical Care Under Workers’ Comp
Assisting Injured Workers Throughout Georgia With Their Medical Questions
If your employer does not have a posted panel,
if the panel is defective or if the employer
otherwise fails to correctly explain your rights to medical care, you are entitled to use any physician you choose, whether or not on the posted panel, and your employer and its insurance company will be responsible for payment of the physician’s bills.
If the panel is valid and you are dissatisfied with the panel physician you chose, you are entitled to make one change to any other panel physician. After the first change, you can change physicians with the employer/insurer’s consent or by filing a petition with the State Board of Workers’ Compensation.
Your treating doctor is authorized to make referrals to other physicians for testing, physical therapy, surgery, counseling or other services for treatment of your injury.
Questions and Answers About Your Medical Care
Q1. What does the panel look like and how many doctors will be listed?
The traditional panel of physicians must have a minimum of six physicians or professional physician associations not affiliated with one another. There must be a minimum of one orthopedic physician and not more than two industrial clinics on the list. The list may be blue or pink and have the words “Official Notice” in large bold letters at the top.
A “conformed panel of physicians” should have a minimum of 10 physicians, including at least one general surgeon and one chiropractor.
Finally, your employer may be part of a workers’ compensation managed care organization (WC/MCO), which is certified by the State Board. In that case, there may not be a traditional or conformed panel. Instead, there will be a notice indicating the name of the WC/MCO and, among other requirements, a 24-hour toll-free number that you can call to obtain medical care.
Your employer is required to post the panel in a prominent location at the workplace. The panel may be posted on a break room bulletin board or next to the time clock.
Q2. Can my employer tell me I have to go to the local clinic before I receive other medical care?
Although this is standard practice for many companies, your employer is not permitted to restrict your right to see any of the physicians on the posted panel.
Q3. How long can I receive medical
care for my injury under workers’ comp?
For accidents occurring before Jul. 1, 2013, you may receive medical care for the rest of your life if required for your injuries. For accidents occurring on or after Jul. 1, 2013, you may receive medical care for a maximum 400 weeks from the date of accident. If you never received Temporary Total Disability or Temporary Partial Disability payments for your injuries, a gap in treatment of a year or more may terminate your right to further treatment. Therefore, unless you are cured, it is important to follow up at least once a year with the authorized treating physician for your injury.
If your injuries are designated as “catastrophic,” you will retain your entitlement to medical care for your injuries for life.
Q4. While on the job I was injured and
taken by ambulance to the emergency room of a local hospital not on the
panel of physicians. Is the workers’ comp insurer
responsible for this bill?
Your employer and their insurer must pay for
medical care from your authorized physician and must pay for emergency
care with any physician or hospital. Your emergency room, ambulance bills
and emergency admission to the hospital for overnight stays should
Q5. My employer says I have to schedule medical visits when I am not working. Is that permitted?
Your employer is not permitted to interfere with your injury-related medical care. If your employer refuses to allow you to attend scheduled medical appointments you can petition the State Board of Workers’ Compensation to order your employer to stop this practice. However, your employer may require that you obtain your medical care at times that does not conflict with your work schedule, as long as it is reasonable.
Q6. Can I do anything about the long time it
takes for the insurance company to
authorize medical care?
Delivery of medical care in the workers’ compensation system is often unreasonably slow. To speed up the authorization process, your physician can send a “Form 205, Request for Authorization of Treatment or Testing” to the insurance adjuster. This is a written request to authorize the requested procedure or referral within five days or the referral is authorized as a matter of law. You can ask your physician or the medical staff to use this procedure. You may be able to assert a claim for penalties against the insurer if the insurance company is consistently slow in authorizing medical care that interferes with your medical care. Contact an experienced attorney for advice.
Q7. Am I entitled to a second opinion concerning my condition or treatment?
If you receive either Temporary Total
Disability (“TTD”) or Temporary Partial Disability (“TPD”) benefits, you
have the right to a second opinion by any physician you choose at the
employer/insurer’s expense. This is known as an “independent medical
IME. You can exercise this right only one time. The physician may perform any test that is medically necessary unless the test was previously performed. If the test was already performed, the physician may order the test again, but the cost of the test must be under $250.
The time in which to exercise your right to the independent evaluation is limited. You can exercise your right to the examination while you are receiving disability benefits and for 120 days after you stop receiving benefits.
If you have not received disability benefits, there is no absolute right to a second opinion. Often, the insurer will allow a second opinion, but they have the right to choose the medical provider.
Finally, there is no limitation on evaluations or treatment from any physician if you are able to afford and willing to pay the fees and costs.
Q8. Will my group health insurance cover my work-related injuries?
Generally, health insurers specifically exclude work-related injuries from coverage. Each health plan has its own policies. You should review your health plan benefits to answer this question.
Q9. Will Medicare or Medicaid cover my work injuries?
Medicare and Medicaid expressly exclude coverage for work-related injuries. As long as you have an open claim for workers’ compensation benefits, Medicare and Medicaid will not pay for medical care for the injuries. However, in some cases, the injured worker may obtain Medicare coverage for his or her work injuries upon settling his or her workers’ compensation claim. This issue is complex and an evolving area of the law. Questions should be referred to an experienced attorney.
Q10. Can I change medical providers if I am dissatisfied?
As stated at the beginning of this section, you have an absolute right to change one time to any other physician listed on the “posted panel.”
If you do not want any of the other physicians listed on the panel to treat you, you must either reach an agreement with your employer/insurer to select another physician, or you should file a petition with the State Board of Workers’ Compensation to request the change in physician. Your employer/insurer may file an objection to your request. Once the State Board makes a decision, anyone dissatisfied with that decision can file an appeal. If you cannot reach agreement with your employer/insurer, you should consult with an experienced attorney before filing a petition.
Q11. My clinic physician says I need to be treated by an orthopedic physician. Do I have to use the orthopedist chosen by my employer/insurer?
No. There is no law that requires you to use
the referral physicians chosen by the insurance company. If the authorized
treating physician makes a referral to a
specific medical provider, you have the right to see that health care professional. You can suggest a physician if none is designated.
Be aware that refusing to accept the medical provider chosen by your employer/insurer may cause problems with your future medical care and can cause delays in treatment if the insurer has complied with the law.
Q12. My employer denied that my injury was work-related and refused to pay for medical care under workers’ comp. As a result, my health insurance or I paid for the health care. Now, the workers’ comp insurance company tells me they will cover my injuries, but insists I use the physicians listed on the panel. Do I have to change physicians?
No. If the employer/insurer denied your claim for medical care under workers’ compensation, they gave up the right to control the selection of your treating physician. As a result, the physician you chose will become the “authorized” physician once the claim is determined to be valid.
Q13. My employer/insurer denied my injuries are work-related so I tried to file a claim under my health insurance. What can I do if the health insurer denies my claim because it is work-related?
Your employer/insurer should send you a written notice that your claim was denied. You should request the written notice if you do not receive it. Your health insurer may provide coverage if you give them a copy of this notice, subject to your agreement to repay the health plan if your workers’ comp claim is later determined to be valid.
Q14. If my employer/insurer denies my claim for disability benefits do they give up the right to control my choice of physicians?
No. If the workers’ comp insurer does not deny medical coverage, but denies your disability benefits, they retain the right to control your access to medical care.
Q15. Am I entitled to be reimbursed for driving to the medical providers?
You are entitled to 40 cents per mile for each
mile you travel to and from appointments with your medical providers,
including tests and physical therapy. You can also receive mileage for
your trips to the pharmacist. The reimbursement rate may change based on
rising or shrinking fuel costs.