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All physicians who treat work- related injuries and illnesses should understand their
state workers’ compensation system. Failing to comply with reporting requirements
and claims filing procedures can deny the patient needed care and delay payment of
physician charges. Physicians should be prepared to provide reports to workers’
compensation hearing examiners. They should also realize that workers’ compensation
laws have not eliminated litigation over workplace injuries. Employees must still
litigate whether their injury was workplace related and the extent of their
incapacitation. Physicians should contact the agency that regulates workers’
compensation in their state for specific information about complying with its claims
procedures.
1. The Payment System
The most important difference in state workers’ compensation systems is who
chooses the treating physician. In general, workers’ compensation costs are lower is
states where the company chooses the medical care providers, and higher where the
patient has the choice. Although it is tempting to infer sinister reasons for this, the
difference is similar in personal medical care insurance. When the company chooses
the providers, the workers’ compensation system tends to resemble managed care or
health maintenance organizations (HMOs). A limited number of providers are used
by the employer or its insurance company. These providers are generally chosen
because they are convenient and cooperative. They may be asked to sign provider
contracts to accept reduced fees. If the outcomes are not good, if the employees are
not getting well and quickly returning to regular work, the provider will be dropped
from the program.
If the employee chooses the physician, the system works more like indemnification
insurance. There are no negotiated discounts to reduce the fee- for-service costs. The
patients tend to “doctor shop” until they find a physician who agrees with their
opinions. And the employee may be given more time off for rest and recovery. Most
states have a system for excluding specific physicians from providing workers’
compensation care if they are clearly biased, but the situations are usually extreme.
The independent medical examiner who did not find a single permanent injury in 20
years of exams, and the orthopedist who took the employee off all work for six
months for a sprained finger are equally unacceptable to the state administrators.
They are not exercising good medical judgment, they are selling paper.
Any physician who is providing care for a work-related injury should base the
decisions about care on his or her best medical judgment. As with any other payment
system, it is not legal or ethical to withhold necessary care because it may not be
covered by the insurance. On the other hand, providing care that is not indicated or
giving employees time off that is not justified borders on fraud. One practice must be
avoided because it is fraud: employees may ask their personal physician to treat them
for a work-related injury and bill the charges to their personal health insurance. Their
motives may be as benign as preferring the doctor they know and trust. However,
their motives may be more complicated. The employee may be dissatisfied with the
amount of treatment or time off they can obtain through the workers’
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