Physician Referrals in a Workers Compensation Claim

Every workers compensation claim is unique in that there are specific injuries that an injured worker has suffered and the seriousness of the injuries usually vary. Because of this, physicians with different specialties may be required to treat the injury. In order for an injured worker to receive authorized treatment from a specialist, a referral from a prior authorized physician is required. Generally when a workers compensation claim is accepted as compensable by the carrier, the injured worker is initially sent to treat with an authorized Primary Care Physician (PCP). From that point, the PCP would have to refer the injured worker to a specialist depending on that physician’s assessment of the injury.

Take for example an employee that injures his back while lifting a heavy item on the job. Assuming the carrier picks up the claim as compensable, the injured worker would be set up with an authorized PCP within that carrier’s network. In order to get specific treatment for the back injury, the PCP would be required to write a prescription for a spine specialist or an orthopedic physician. Lets assume that an orthopedic physician has been authorized. If the orthopedic physician opines that the injured worker requires treatment with a pain management specialist or if the worker is suffering from mental anguish due to the impact that the injury has had on his life and the orthopedic physician believes that a psychiatrist is needed, a referral to these types of physicians would once again be required. Further, depending on how many body parts the employee has injured, many different physicians may be required to give the best possible treatment to the specific body parts that were injured in the accident. If a treating physician opines that surgery is required, however that particular physician does not perform surgery, a referral would be needed to a surgeon that treats that type of injury.

The advantage of having an attorney on the claim when a specific physician has been recommended is the filing of the Petition for Benefits. An attorney files a Petition for Benefits with the Court which this puts pressure on the insurance company to set up the recommended physician within a certain time period or they may be required to pay the attorney a fee. That is why it is important to hire a Workers’ Compensation attorney who handles these types of situations in order to get advice about how to proceed with the case. If you are in this situation or know of someone who is, have them give us a call at (772) 461-9181.

This article is general information, not legal advice. Every case is different - call (561) 598-7120 for a free consultation about yours.