Medical Care Under Workers’ Comp
If you are injured on
the job, you are entitled to medical care for your injury without co-pays
or deductibles. The law gives your employer and its insurance company the
right to control which physicians treat you. Your employer must post at
the work site or office a list of treating physicians if you are injured
on the job. This is known as the “panel of physicians,” or “posted panel.”
Your employer is required to explain your rights and the procedure for use
of the panel physicians if you are injured.
Assisting Injured Workers Throughout Georgia With Their
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
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
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
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
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
Q9. Will Medicare or Medicaid cover my work
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
Q10. Can I change medical providers if I am
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
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
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
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.
our experienced attorney regarding your choice of doctor after a work