The Injured Workers Puzzle Picture Part 4: Choosing Your Treating Physician

When you are suffering from an injury, you want and deserve immediate medical attention from a physician that is concerned about all of your treatment needs. After all, your health is your most precious asset. 

 Polling consistently shows that American’s feel strongly about the right to choose their doctor for treatment. 

 In the California workers’ compensation system; however, insurance companies try to limit your choice of treating physicians by insisting you use their “Medical Provider Network” (MPN).

 An MPN is a listing of doctors hand-picked by the insurance company, and each physician is required to sign a contract that requires that the physician follow insurance company rules, and are subject to being kicked out of the MPN if they don’t. Since being a member of an MPN can be a tremendous source of business for a physician, its easy to see why a physician wants to stay in the insurance company’s “good graces.” 

 Which “master” does the physician serve – the patient or the insurance company? For example, does the physician recommend the necessary surgery at the risk of being kicked out of the MPN? Ask yourself this question: are your medical needs worth the risk of losing the physicians’ membership in the lucrative MPN? You know the unfortunate answer. 

 Claims adjusters will tell you to “pick another MPN doctor” if you don’t like the one you have. But the business considerations will be the same with any physician in the MPN network. 

 Pretty depressing, right? All you want is to get prompt, effective treatment so that you can get back to work, but the treating physician has a substantial built-in moral conflict to resolve. 

 You are not the only one who is facing this problem. Many of the injured workers that call me after a work injury do so because:

• The MPN physician changes every time they have an appointment
• They see a Physician Assistant (PA) instead of a physician
• A nurse from the insurance company is telling the physician what to do
• The physician refuses to make a referral to a specialist
• The physician won’t ask for the necessary treatment because “it will be denied anyway.”
• The physician refuses to treat ALL the work injuries because “the claims adjuster won’t authorize it”. 
• The physician won’t acknowledge other injuries and conditions even though they relate to the work accident.

The list goes on, but the underlying theme is the MPN physician(s) isn’t looking out for YOU, the injured worker.

Fortunately, the law states you may be able to select a NON MPN treating physician when:

• The MPN physician fails to fully document your injuries.
• The MPN physician fails to send you to a specialist even though one is necessary.
• The claims adjuster refuses to authorize treatment for ALL of your injuries.
• The employer did not provide you MPN notices at the time of hire.
•  The MPN physician won’t treat you for conditions that later arise from the original injury ( like your back hurting after a knee injury). 
•  No MPN notices were provided to you after the injury.
• Your treatment is delayed.
• The MPN physician won’t treat ALL of your injuries.

Because every case is unique, these are just some of the circumstances which may give you the right to choose a non-MPN physician to treat you for your work injuries at the claims administrator’s expense.

Regaining your health as quickly as possible it what you deserve. Requiring the claims administrator to provide ALL of the care the law requires is not only law but the right thing to do.

Even with great physicians treating you, claims administrators still use “Utilization Review” to block the physicians’ treatment recommendations.

 We’ll cover that in the next segment.

 – Tom Martin