Physician Choice: Whose Right Is it?

When an employee suffers a work-related injury, workers’ compensation law obligates the employer to pay for medical treatment. Who gets to choose the treating physician—and why does it matter?

In some states, the employer gets to choose the physician and all medical providers. This is called a full control program. In this type of system, covered employees can seek a second opinion if they are unsatisfied with their care and provide evidence that their care is inadequate, or if the employer fails to notify employees of their rights or neglects to enforce its rights to full control.

In a partial control program, the employer selects and posts a list of medical providers. It has the right to require employees to use one of these approved providers for a period of time specified by workers’ compensation laws. Medical providers must have the skills and qualifications to treat workers’ injuries or refer them to specialists with the employer’s approval. After the initial period of employer control, the employee may continue using those employer-selected providers or choose their own. If the employee feels his/her care is inadequate, he or she will have to submit to an independent medical exam, and the employer may suspend workers’ compensation payments until the employee complies.

Some states have medical panels. In this type of system, the workers’ compensation jurisdiction (the state) maintains a list of approved medical providers. The employer and employee work together to select the providers that offer the best possibility of recovery. This model occurs most frequently in monopolistic states, in which the state’s workers’ compensation organization pays all claims.

Finally, some states allow free choice, where employees can use whatever licensed providers they choose. Some of these states require the employee to designate a “primary treating physician” before they are injured. For example, California requires employees to provide their employer with the name of a licensed medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or a medical group with an M.D. or D.O. as the doctor with overall responsibility for treating their injuries. If employees do not predesignate a doctor, the employee must select a doctor from the employer’s medical provider network. If the employer does not have a medical provider network, the employee must go to a doctor selected by the employer during the first 30 days after injury.

Why Does Physician Choice Matter?

While claimants perpetrate some types of workers’ compensation fraud, such as passing off non-work injuries as work-related or malingering, physicians can also be guilty of fraud. Dishonest medical clinics, or claims mills, can scam insurers out of millions of dollars by inflating injuries or giving illegal kickbacks to workers. Others might have no licensed doctors and little useful medical equipment. The use of medical provider networks helps employers by ensuring that employees will be treated by pre-screened providers. And it can help injured workers by ensuring that they will be treated by a practitioner qualified and experienced in treating workers’ compensation injuries.