Can You See Your Own Doctor on Workers’ Comp?

Posted on June 11, 2020

If you have been injured in a workplace accident in Illinois, you may be wondering – can you see your own doctor on workers’ comp? You can select your own doctor, subject to certain limitations on what doctors you can choose from or how many second opinions you are able to get. A workplace accident can be a traumatic and disruptive event. After any injury, it will help you to have peace of mind knowing that you can select a trusted doctor and feel confident in your healthcare.

What Is a Preferred Provider Program?

A Preferred Providers Program (PPP) is a type of health plan where a health provider contracts with insurers to provide services at a discount. Employers providing workers’ compensation insurance often use PPPs.

Workers’ compensation is a type of insurance provided by employers for their employees in case they are injured or becomes ill at work. It provides employees with compensation for missed wages if they need time off work. It also gives benefits for medical expenses to treat the illness or injury, as well as vocational rehabilitation if ongoing care is needed to get employees back to work.

Employers providing workers’ comp insurance to their employees can make use of PPPs. This allows employers to nominate a network of doctors, hospitals, and other medical care providers to treat employees who have suffered injuries. Using PPPs allows medical services to be provided at a lower cost.

In Illinois, PPPs must be approved by the Illinois Department of Insurance. The Department will review each applicant to make sure that the medical provider is able to provide quality care.

The PPP program has dual benefits. It allows employers to control medical costs, while at the same time ensuring that the employee has quality choice of healthcare providers.

In situations where an employee suffers an injury while on the job, the employer must notify the employee whether it uses a PPP for its workers’ compensation claims. When deciding how to find a workers’ comp doctor, the employee can choose two doctors from within the network to treat him or her. The employee is not bound to select doctors from the PPP. If the employee does not wish to select a doctor from the PPP, he or she must notify the employer in writing, although he or she is then limited to one choice of medical provider only.

If the employer does not use a PPP, then the employee has two choices of medical providers and is able to select from any healthcare provider.

There are certain situations where an employee is permitted to seek treatment from a healthcare provider outside a PPP, even if the employer uses a PPP:

  • A job-related accident creates the need for immediate emergency treatment.
  • The employee requires care before he or she is able to report the injury to his or her employer.
  • The employee has decided to opt out of the PPP network.

There are certain drawbacks to using a PPP. PPPs limit the choices that an employee has for healthcare providers. Employers’ priorities may be to minimize costs and have employees back at work as soon as possible. Therefore, employers might choose PPPs that offer minimal treatment to minimize costs and urge employees to return to work before they have fully recovered from their injuries. In exchange for offering lower costs, there is a risk to injured Illinois workers.

The Two-Doctor Rule

You as an employee are protected by the two-doctor rule in Illinois. You are permitted to see two doctors in a referral chain. A referral chain comprises your initial work injury doctor and all subsequent referrals.

For example, you may see a general practitioner who refers you to an orthopedic surgeon, who then refers you to a pain management doctor, who refers you to a physical rehabilitation physician. This is one referral chain. You still have another referral chain that is started by visiting another doctor with all subsequent referrals. You would likely use the second referral chain for a second opinion. However, if your employer uses a PPP, and you wish to use a doctor outside a PPP, you will only have one referral chain available.

When Can an Employer Order an Independent Medical Evaluation?

In Illinois, an Independent Medical Examination (IME) can be ordered by an employer or insurance company. An employer or the insurance company will require an IME if it disputes the physician’s opinion, or requires more proof to validate the injuries before approving the claim. An IME is a report issued by a doctor who has not treated the employee, nor been involved in the care in any way.

What Is the Purpose of an IME?

An IME is performed by an independent doctor to present an unbiased report. The insurance company will often require an IME if it disagrees with the doctor’s diagnosis, usually in cases where the diagnosis requires extensive treatment, surgery, or reports a permanent disability.

An IME assesses the cause of the injuries, to determine that they were caused by the workplace accident. It determines the nature and extent of the injury, and clarifies or confirms the diagnosis given by the initial treating doctor. It also assesses whether the care given so far, as well as the care recommended going forward and the length of care, is appropriate, and offers treatment recommendations if required. The IME suggests a date for the employee to reach maximum medical improvement, which is the point at which the employee’s condition has reached a point that it is not likely to recover any further. It assesses whether there are any disabilities that will remain after treatment, and if there are any medical or work restrictions.

What Happens During an IME?

The IME doctor will receive all existing documents relating to the employee’s medical history, as well as the injury report. If the insurance company is disputing the claim, it will send a letter to the IME doctor with specific questions. These can include questions on:

  • Whether the condition has been diagnosed correctly.
  • Whether it was possible that the condition or injuries were due to some cause other than the work-related accident, such as personal activities.
  • If extra medical treatment or testing is needed for the condition, and if so, what treatment.
  • When, or if, the employee will be able to return to work. 
  • If there will be restrictions on what the employee can do at work.
  • If the employee has suffered permanent disabilities, and if so, the extent of them.

What to Do During an IME

If you have suffered a workplace injury, and subsequently made a workers’ comp claim, you may be required to undergo an IME. In such a situation, you should be aware of what to do, and what to avoid, to increase your chances of a favorable outcome int your claim.

When undergoing an IME, you should prepare for the examination by reviewing your medical records and treatment history. Be ready to discuss these with your examining doctor. You should also make sure that all paperwork is filled out as accurately as possible, as any discrepancies between the doctor’s observations and the paperwork will probably be noted in the report.

You should be aware of what to say, as well as what not to say, to your workers’ comp doctor. Provide accurate information to the doctor by being honest about your condition and symptoms. Avoid exaggerating or downplaying your injuries, being confrontational or argumentative, or refusing to answer questions. Also, avoid speculating or guessing any details that you do not remember or are unsure of.

You should take notes after the examination, with details about the questions asked and what tests were performed. If a doctor only conducts a brief exam, such as asking a few questions and then leaving the room, the examination will not have been thorough and will likely have less weight given to it than a thorough, objective medical examination.

If you have a workers’ compensation attorney, you should report the details of the IME to him or her afterward. This will assist your attorney in protecting your rights, as your attorney can dispute the results of the exam if it was not performed satisfactorily. Reporting to your attorney will help him or her handle your case appropriately.

The Impact of Choosing a Doctor for a Workplace Injury

If you have suffered a workplace injury, you may be wondering – ‘how long do I have to see a doctor after a work injury?’, as well the impact of choosing a good doctor. There is no law regarding how soon to see a doctor, although the longer you wait, the harder it will be to prove your claim.

Selecting a good doctor can have a huge impact on your case. This is because medical records, as well as having the correct diagnosis, are crucial pieces of evidence for your claim.

There are several reasons it is vital to choose the correct doctor for your workplace injury:

Receiving the Best Medical Care Available

If the doctor is offering you minimal treatment, not ordering the proper tests, or rushing you back to work, you are likely not receiving the best treatment available. Your treatment can affect your livelihood. Receiving inadequate treatment can have long-lasting effects, as your injuries may not heal properly. If you can select a doctor with whom you feel comfortable, you can feel confident in your medical treatment.

The Medical Diagnosis and Treatment Affect Your Wage Loss Claim

If your injury has long-term effects, the recommendations from your doctor will impact your claim for future loss of earnings. Your treating doctor classifies any disability that you might have. He or she indicates if, when, and to what extent you are able to work again. Your doctor will assign disability ratings if you have suffered a partial disability, or report what restrictions you have going forward.

With a report and recommendations, you can better calculate your lost wages and lost earning capacity, and will thus be able to know what benefits to claim.

The Medical Diagnosis Provides Evidence for Your Claim

The report from your doctor will be used as evidence in supporting your claim. It will provide proof of your injuries, as well as their extent, and link them to the accident.

Your doctor’s records will also dictate what medical bills are to be paid by workers’ comp. This includes costs associated with your diagnosis and treatment, such as doctor visits, medical devices, physical therapy, diagnostic tests including x-rays, MRIs or CT scans, and medication.

If your doctor’s notes and evidence are comprehensive and thorough, you have a much better chance of receiving higher compensation.

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