One of the mainstays of workers’ compensation insurance is that there will be timely, reliable medical care available for injured workers. According to the Workers’ Compensation Act, the employer/insurer are required to furnish the employee:
“...such medical, surgical, and hospital care and other treatment, items, and services which are prescribed by a licensed physician, including medical and surgical supplies, artificial members, and prosthetic devices and aids damaged or destroyed in a compensable accident, which in the judgment of the State Board of Workers’ Compensation shall be reasonably required and appear likely to effect a cure, give relief, or restore the employee to suitable employment.”
Further, the medical treatment/expenses must be reasonable and customary, and prescribed by the authorized treating physician (ATP). But how does an injured worker select one?
Every employer that is subject to the Act must post a panel of physicians from which the employee may select their treating physician. There are two types of panels — traditional and conformed — and a third variation: a Managed Care Organization (MCO).
Under current law, the traditional panel must:
- Have at least six “unassociated” physicians or professional associations of physicians who are close in proximity for the injured worker;
- At least one of the physicians must be an orthopedic surgeon;
- No more than two of the six physicians can be an industrial clinic;
- According to Board Rule 201(a), one of the six physicians must be a minority physician. The term “minority” is defined as “a group which has been subjected to prejudice based on race, color, sex, handicap or national origin, including, but not limited to Black Americans, Hispanic Americans, Native Americans or Asian Americans.” It is important to note that the Board Rule immediately contradicts its previous “requirements” by noting the “[F]ailure to include one minority physician on the panel does not necessarily render the panel invalid.”
The employer is required to post the panel of doctors in prominent places upon the business premises, usually in a break room or near a time clock. The employer is also charged with the responsibility of making sure the employee understands the “function of the panel” and the “employee’s right to select a physician” from the panel, as well as being required to give assistance to the employee to contact the physicians on the panel.
With a traditional panel, once the employee selects the physician to provide treatment, then this physician is designated as the “authorized treating physician.” The employee is also allowed to make a one-time change from the ATP to another doctor on the panel of physicians.
Conformed Panel of Physicians
A Conformed Panel of Physicians must have at least 10 physicians or professional associations of doctors that are reasonably accessible to the injured worker. The list can also contain general surgeons and chiropractors. The 10 physicians or groups of physicians cannot be associated. The Board also requires that at least one of the 10 be a minority physician.
Managed Care Organization
An MCO is a “plan certified by the Board that provides for the delivery and management of treatment to injured employees under the Georgia Workers’ Compensation Act.” The employer is required to post notices about the MCO in prominent places around the workplace and make efforts to ensure the employee understands how the MCO works.
What happens if an employer fails to comply with the law?
If an employer does not post a panel of physicians or, in the alternative, posts a panel that is not in compliance with O.C.G.A. Section 34-9-201 and Board Rule 201, then the employee is free to select the physician of their choice to provide treatment and the employer/insurer has to pay for it. The physician selected becomes the ATP. Once this physician is selected, the employee may make a one-time change to another physician without employer approval or approval of the Board.
Authorized Treating Physician
When an ATP is selected by the injured worker, this physician may refer to other doctors and physicians for “specialized” testing or treatment. However, these physicians may not refer to any other doctors as only the ATP is vested with this power. However, if the ATP agrees with the specialist’s referral, the ATP may concur and refer to this specialist.
What happens if the employee is injured and needs emergency medical attention? Will the emergency room visit be covered if the hospital is not one of the “physicians” on the panel of physicians? The emergency visit will be covered as long as the emergency “exists”; once the emergency is over, the employee is required to comply with the panel of physician requirements.
Refusing to Treat
Another problem can arise when the ATP refuses to treat the injured worker. This can happen in two ways:
- The ATP refuses to provide treatment to the injured worker; or
- The ATP releases the injured worker from their care.
In (1), the employee must produce evidence that the ATP would not see them and that they refused to schedule an appointment. In (2), the situation often arises when the ATP dismisses the employee from their care and opines that the worker does not need any more treatment. If the injured worker can demonstrate that they are in need of care despite the ATP’s dismissal, then the employer/insurer may be liable for continuing treatment with a doctor of the employee’s choosing.
If the employer/insurer have controverted the entire claim — meaning they are denying that the accident and injury arose out of and in the course and scope of employment — and the claim is later accepted voluntarily or the Board finds the claim compensable, the medical care the injured worker has received can be claimed as authorized and submitted to the employer/insurer for payment. The treating physician becomes the ATP, and the injured worker is entitled to a one-time change to a physician of their choice.
Assuming the panel of physicians is valid under Georgia law, and the employee has already exercised their “one-time change” to another doctor on the panel, how can an injured worker change physicians again? There may be a personality conflict between the patient and the doctor. The doctor may have a horrible bed-side manner and does not listen to the injured worker or they may consider the worker’s complaints as whining or complaining.
In this doctor-patient relationship, with that kind of distrust or poor communication, it is certainly not in the patient’s best interest to continue treating with that physician. There are two ways this change can be effectuated:
- By agreement with the employer/insurer; or
- By filing a Motion to Change Physicians with the State Board of Workers’ Compensation.
- If a Motion to Change Physicians is filed by either the injured worker or the employer/insurer, the Board will look at the following factors when it considers granting or rejecting the request for a change:Proximity of physician’s office to employee’s residence
- Accessibility of physician to employee
- Excessive/redundant performance of medical procedures
- Necessity for specialized medical care
- Language barrier
- Referral by ATP
- Noncompliance of physician with Board Rules and procedures
- Panel of physicians
- Duration of treatment without appreciable improvement
- Number of prior treating physicians
- Prior requests for change of physician/treatment
- Employee released to normal duty work by current ATP
- Current physician indicates nothing more to offer
Navigating Medical Costs After Treatment
Medical expenses and other treatment costs for injured workers within the workers’ compensation system are supposed to be paid by the employer or insurer within 30 days of receiving the bill. Health care providers are not supposed to bill the injured worker for the cost of medical care. The medical provider must submit the charges to the employer/insurer for payment within one year of the date of service.
The medical bills are limited to “the usual, customary, and reasonable charges as found by the Board pursuant to O.C.G.A. Section 34-9-205.” All bills submitted to the employer/insurer for payment by the health care providers must be submitted on proper Board forms, as “[N]o physician, hospital, or any other provider of services shall be entitled to collect any fee unless reports required by the board have been made.”
It is important to note that all healthcare providers must bill according to a fee schedule set up by the Board. Their liability for bills “shall be limited to such charges as prevail in the State of Georgia for similar treatment of injured persons of a like standard of living when such treatment is paid for by the injured persons.”
- A hospital may charge $200 for an X-ray.
- The fee schedule may limit the X-ray to $75.
- The hospital will be paid $75 by the employer/insurer.
- The hospital cannot bill the employee for the excess amount of the bill ($125.00), as this amount must be written off.
Will I ever be able to see a doctor of my choice and make the employer/insurer pay for it?
This is a question we are often asked. The simple answer is: it depends. If an employee has received any weekly indemnity benefits for their on-the-job injury “and within 120 days of receipt of any income benefits, [they] shall have the right to one examination at a reasonable time and place, within this state or within 50 miles of the employee’s residence, by a duly qualified physician or surgeon designated by the employee and to be paid for by the employer.”
These examinations shall include “physical, psychiatric and psychological examinations” and it “shall also include reasonable and necessary testing as ordered by the examining physician.” It is also important to note the employer/insurer may require the employee to attend a second opinion with a doctor of the employer/insurer’s choosing for a second opinion.
When an employee has sustained an injury and the injury has been accepted by the employer/insurer as compensable, the employee may — under certain circumstances — be entitled to “reasonable and necessary rehabilitation services.” If the injury is catastrophic “the employer shall furnish the employee entitled to benefits under this chapter with reasonable and necessary rehabilitation services.”
Within 48 hours of the injury being accepted as compensable and catastrophic, the employer/insurer must appoint a rehabilitation supplier and is required to file a Form WC-R1 with the State Board, along with the Employer’s First Report of Injury form or within 15 days of notification that rehabilitation is necessary.
As you might imagine, the costs of hiring a rehabilitation supplier and providing rehabilitation benefits to the injured worker can get very expensive for the employer/insurer. Every rehab supplier that handles workers’ compensation claims in this state must be certified or licensed and registered with the State Board.
Generally, rehabilitation benefits can include:
- a vocational assessment and evaluation
- vocational planning and training
- possible advanced education
- home or vehicle modifications to aid the injured worker
One benefit often overlooked by injured workers is their right to receive reimbursement for mileage to and from their medical appointments. This even includes trips to get prescriptions filled. We provide our clients with a form that helps them to catalog each trip. This form includes the date the trip was taken, the purpose of the trip, and the number of round trip miles.
In addition, any charges for parking are also reimbursable expenses.
Hiring an Atlanta Workers’ Compensation Attorney
It can be frustrating if the doctor chosen for your workers’ compensation case is ignoring your pain or they live far from your home. Your employer may be ignoring your requests or refusing to pay for certain medical services.
Let our experienced workers’ compensation lawyers and case managers work with you to get the best medical care possible. Our team will ensure that your injuries are taken seriously and treated by a physician you feel comfortable with.
If you have questions about your work injury claim or need help filing for workers’ compensation because the insurance company and your employer aren’t concerned with your well-being, contact our Atlanta workers’ compensation lawyers today.
This is Part 2 of the Georgia workers’ compensation benefits series.
Part 1: Workers’ Compensation and Wage Benefits Explained by a Lawyer
Part 3: Workers’ Compensation and Permanent Partial Disability Benefits Explained by a Lawyer