Choosing a Doctor

Yes, you do have the right to choose your own doctor under the rules established by California’s workers’ compensation laws. However, it is not an absolute right but one that is subject to certain restrictions and conditions. First of all, the injury itself that is treated had to be covered by workers’ compensation insurance. Any injury sustained at the workplace or while off-site performing work-related duties for your employer will count. Anything stemming from those injuries is also covered.

In order to have the right to use the doctor of your choice, you have to predesignate that doctor. This means you tell your employer about your preference for a particular doctor (in writing) at the appointed time each year. You can’t designate your preferred doctor last-minute after an accident but must do so ahead of time.

Also, not every worker is allowed to predesignate. Some employers have insurance companies that might restrict the network. Plus, you have to have your own health insurance so it will cover any medical expenses that are not work-related when and if you see that doctor.

If you qualify to predesignate your own doctor, you can just turn in your request in your own signed statement, fill out a form provided by your employer, or fill out DWC form 9783. You might have to use the DW form 1194 in some cases. And the doctor you choose has to meet specific standards, such as having the right license and already being “your doctor” before you predesignate.

After a workplace accidental injury, your first priority is to get top-tier medical care without delay. This may mean being taken straight from the injury site to the ER in an ambulance. In that case, there’s really no decision on where to go - you will get to the closest hospital or the one designated by you or your employer ahead of time.

Your physician who treats your workers-comp covered injuries will be responsible to diagnose you and decide if he or she believes it was caused by a poor or unsafe work condition. He will also recommend surgeries or other specific treatments. He will need to recommend you to any specialists you will see. Your doctor will also have a say in how much time you need off work to fully recover or to at least recover enough to return to work. Your treating physician may also set limits on what you can do at work (such as avoiding heavy lifting.) Finally, your chosen doctor will have to declare when your medical condition has become “stable,” meaning you have reached your full recovery point. All of this will impact not only the type of care you receive but also how much disability compensation you will receive (be it temporary, permanent, full, or partial.)

If you have already predesignated your physician ahead of time, your employer or the workers’ comp insurance company cannot suddenly decide you have to see a different doctor. You have a right to stick with your own chosen primary care physician (PCP.) However, if you lack health insurance, that right can be canceled. And if you failed to predesignate or your doctor did not agree to your designation of him/her, then you do not have that right. In that case, you will see whatever doctor your employer has designated for you.

On the other hand, there are some situations where you may be able to see your own doctor and have it covered in spite of not having predesignated him. This might occur if you were never informed of your right to select your own doctor or if your employer delayed to give you a workers’ comp claim form after you reported the work-related injury to him. If either of these two things happens, state law lets you see your own doctor first since it appears that the employer may not cooperate and deal fairly with covering your needed medical care.

If your employer is in an MPN (medical provider network) and you did not predesignate (and your employer followed the law), then you will have to choose an in-network physician. In times of emergency care, however, you may see any doctor and have it covered by workers’ comp. In other cases, your employer may have a contract with a healthcare organization (HCO). In that case, the insurance company’s claims’ administrator will select your doctor for you for the first thirty days of treatment.

Also note that for very minor injuries, your employer will normally have the right to designate the treating physician for you. For more severe injuries, your rights are more expansive.

It is not uncommon for those filing a workers’ compensation claim to become dissatisfied with the doctor they see first. The first physician to see and treat you may not believe you that it was a work-related injury or may refuse to recommend needful medical treatment. Or, he or she may not give you adequate time off work to recover, while being compensated for the loss of income.

You have the right to ask for a second opinion, and you can even seek a third opinion. You may have to stay with an in-network provider for all opinions. If you don’t trust the opinion given by your own predesignated PCP, then you would have to get additional opinions from doctors in your employer’s network or in contract with your employer.

But for the most part, you will trust your own doctor most. You already have a preexisting relationship with him or her, after all. When an employer-selected doctor seems to favor your employer and unfairly refuse you the care and compensation you need, it may be time to seek to change doctors.

Let’s say that, for whatever reason, you are not satisfied with your current doctor who has been seeing you for work-related injuries. You can’t get the care you believe you need or your compensation is at stake. What do you do?

To avoid denial or reduction of your benefits, you can get a second opinion and switch treating physicians under California law. There are regulations on how to do this, and if you don’t follow them precisely, the insurance company involved may try to get out of paying for any of your medical treatment. That’s why you need a good workers’ comp lawyer to guide you through this process.

To make the switch, you also need to know whether your employer has an MPN, a contracted HCO, or neither. It will determine how to process works.

If you predesignated with your PCP and want to switch, you can do so anytime. But you will have to then go with a doctor in your employer’s network or HCO and let your employer or his insurance company make the choice.

If your employer has no MPN or HCO in place, here are the rules for selecting a new doctor. You can switch one time only within the first 30 days, but you don’t choose the new doctor - the insurer does. After 30 days, however, you then have the right to switch and to choose which doctor you want to switch to. And you can switch more than once if you feel it’s necessary. There really is no limit of how many times you can switch, but it just becomes more hassle to keep switching again and again.

When your employer has a medical provider network (MPN) in place and you did not predesignate your own physician, you can switch doctors two times. But you have to stay in-network. If you still strongly disagree with the third in-network doctor, you can apply for an independent medical review to be run on him or her. This is where a “neutral” medical professional evaluates the situation and decides whether or not you will be allowed to choose an out-of-network doctor.

If you did not predesignate and your employer has a contract with a healthcare organization (HCO), you can choose a new doctor only once in many cases. And the HCO itself will decide on the new doctor, which must also be in-network. To switch outside of the HCO network, you have to wait 90 days if your health insurance is not through your employer. If your health insurance is through your employer, the waiting period is twice as long (180 days) for switching outside the HCO.

When you do have the opportunity to choose your own treating physician to see you about a work-related injury - whether as the first doctor or one you switched to, you want to exercise wisdom in making that choice. Here are some basic guidelines to consider in selecting the doctor that will benefit you the most:

• Choose a doctor who has the full range of expertise to deal with your medical needs.
• Be sure you feel comfortable with your physician. It has to be someone you can trust.
• It’s important that the doctor’s office be reasonably close to your home and place of work.
• Your doctor must be honest. He or she can’t be loyal to your employer your employer’s insurer first and foremost.
• It’s best if you have a prior relationship with your doctor. A PCP or former PCP is ideal.
• Be sure the doctor’s services are covered by your regular health insurance besides just by workers’ compensation insurance.
• Look for a doctor who has connections so he can recommend you to specialists as needed.
• Make sure your treating physician has experience in working with workers’ comp and related paperwork. He should understand how his decisions will impact your compensation.

Choose the right doctor the first time, and you can save a lot of headaches later on. But no one can predict the future either. If you end up needing to switch doctors, we can help you navigate the process so you will meet all requirements and not lose any compensation.

Good workers don’t want to miss any time at work, and you may also be worried about whether or not you will get paid if you see the doctor on a workday. No One plans for an accident or another medical emergency. But they still happen, and when they do, you need to waste no time in getting the medical care you need. You should also waste no time in filing a workers’ compensation claim with your employer following a work-related injury.

Now, if you just took off work randomly or to see the dentist, you wouldn’t still get paid for those lost hours. If you go for a non-work-related condition or when it is not a medical emergency and you could have just gone later when you weren’t scheduled to work, don’t expect to be paid for the time you spent at the doctor. But job-related injuries are a different story. You cannot be penalized for seeing the doctor promptly for a work-related injury or emergency medical need.

With work-related injuries, California law declares that your employer must actually pay you for the time you spent waiting for medical care and receiving it if you would have been at work otherwise. This is a part of the Fair Labor Standards Act. But you do not get paid for time at the doctor’s office if it wasn’t originally part of your scheduled work day that day.

Also, if you end up having to see your doctor in follow up visits later on, and your employer or his insurance company requires such visits, then you will be paid for them IF they also cause you to take extra time off work. However, you will not see this compensation in your paycheck. Instead, it will show up as part of your workers’ comp benefits. Specifically, it is counted as one day’s worth of “temporary disability indemnity.”

Both the federal Fair Labor Standards Act and California’s Labor Code in Section 4600 require this kind of compensation for doctor’s appointments under these very specific circumstances. Your employer or his workers’ comp insurer can’t just decide not to pay you for it because “if you aren’t working we won’t pay you.” And you also are entitled to compensation for travel time, wait time, meals, and even hotels (if any of this is necessary) for such doctor’s or specialist’s appointments. As it can be tricky to understand exactly how this system works, it is best to rely on an experienced attorney so you won’t lose any of your rightful benefits.

You may be wondering, “Do I have to wait for my workers’ compensation claim to be approved before I can receive any covered medical care?” The answer is a resounding “no!” Obviously, such an arrangement could endanger the health of injured workers by denying them treatment early on after an injury, which is usually the most critical time.

After you file your claim, the insurance company is supposed to immediately begin covering your necessary medical care. Even while the insurance adjuster is still considering whether to approve or deny your claim, you are allowed up to $10,000 of coverage for medical costs stemming from the work-related injury. The insurer has only 90 days to give you an answer on your claim application - they can’t just ignore you. If they give no response after 90 days, your claim is automatically approved under California Labor Code Section 5402.

California law stipulates that if an injury occurred on the job site or while working for your employer in some capacity away from the job site, the medical expense is to be covered by workers’ comp insurance. And all medical procedures that are needed to “cure or relieve” the condition must be covered.

You should not be charged a deductible or any out of pocket expenses for doctor’s visits or other medical care. All the medical bills, be it a physician’s bill, hospital bill, prescription medications, or necessary medical equipment are to be 100% taken care of. And you even have the right to have 24 sessions with a chiropractor or other therapist covered.

One of the key reasons to be careful in choosing your doctor, wherever you are allowed to, is so you will get the treatment you need without attempted obstructions (designed to reduce expenses for the employer or his insurer.) That’s why you should normally prefer to predesignate your own familiar primary care physician.

However, even after your doctor recommends an operation or other medical procedure or expense, that’s not the end of the process. The doctors too are subject to review. In what is called “utilization review,” the insurer will determine if they think the recommended treatment is truly “medically necessary” for you.

You can’t control which insurer your employer uses, and you obviously don’t want to switch employers needlessly and lose your job. But what you may be able to control (depending on your situation) is which doctor you use in connection with workers’ comp covered injuries. If the insurance company opposes the doctor’s recommendation, then you may need assistance from your workers’ comp lawyer in overcoming that kind of a blockage. Choose your doctor well where you can, and choose your attorney well - that’s the best way to prepare to win your maximum benefits after a work-related injury.

You cannot simply choose your own specialist doctor to treat you for a workers’ comp covered injury. All you can do is choose your primary care physician via predesignation or by going through the process to select a new doctor if you aren’t satisfied with the care you are getting.

But one of the key roles of your doctor will be to refer you to a specialist. It is extremely common for those suffering from serious workplace injuries to need specialty care, so you want to choose a doctor who is willing to refer you to specialists. You also need to consider if your doctor has experience in making such referrals for your type of condition - you want someone who can get you to the best available care. You want, ideally, a primary doctor who has long-standing relationships with specialists so he or she can confidently recommend you to someone who will treat you right.

Choosing the right doctor for your work-related injuries or condition is a big step. There is much at stake, and there are many regulations and rules that must be met to ensure your doctor’s bills will all be covered by Workers’ Compensation.

At Workers Compensation Attorney Law Firm, we have deep experience in assisting injured workers in Los Angeles and all L.A. County to choose the doctor they prefer, trust, and who will meet all their needs.

For a free consultation on your workers’ compensation case, or for help in choosing the best doctor, contact us anytime 24/7/365 by calling Los Angeles work injury attorney at 310-956-4277!