What to Do When You’re Told a Workers’ Comp Doctor Referral Is out of Network
It’s frustrating enough being out of work and in pain because of an injury that happened on the job. Now you’re being told your workers’ comp doctor referral is out of network.
Let’s say you were in a car accident not related to work. You go to an in-network doctor for initial treatment. Then, this in-network doctor refers you to an out-of-network physical therapist. In this case, it means you must pay for your physical therapist appointments yourself – or get a referral for an in-network physical therapist.
This type of situation is a pain. And not just for patients but also for doctors.
Battling your insurance company about an out-of-network referral is always annoying – but battling about a workers’ comp doctor referral shouldn’t even happen in the first place.
Why?
Networks serve ZERO purpose when it comes to workers’ compensation because workers’ compensation insurance operates differently.
One of these key differences is in handling workers’ comp doctor referrals.
Networks Are Irrelevant to Workers’ Comp
Doctors’ offices and medical providers are so used to group health insurance networks that they can easily confuse this traditional network system with workers’ compensation.
Like traditional medical insurance, workers’ compensation insurance has plenty of hoops to jump through.
For example, you get to choose which doctor you want to treat you following a workplace injury – as long as you choose from the posted panel of physicians.
Once you have chosen this doctor (your authorized treating physician), this doctor is now in charge of your care, including any workers’ comp doctor referrals.
This is why choosing your workers’ comp authorized treating physician from the posted panel of physicians yourself is critical rather than simply going to the doctor your employer suggests.
You want an ethical physician who will strive to get the best quality of care for you, which includes writing you the most appropriate workers’ comp doctor referrals.
Now that I’ve made this clear, let’s back up.
You do not use your insurance for treating a work injury. It falls under workers’ compensation.
This means you don’t have to worry about going to see an in-network doctor. If you are going to need further testing or treatment, you don’t have to worry about networks either.
Since doctors are so used to working with group health insurance networks, they can be tricked by workers’ comp insurance adjusters and made to believe they have referred a workers’ comp claimant to an out-of-network doctor.
I recently had a client call because an adjuster got a doctor’s office to change a workers’ comp doctor referral because the doctor they suggested was “out of network.”
This is a blatant lie.
If a doctor says my client needs to have physical therapy at a specific location, that’s it – it needs to be authorized there. Whether they’re “in-network” with the workers’ comp insurance company or not doesn’t matter.
Why would an insurance adjuster try to trick the doctor’s office? The answer is simple – to save money!
If the adjuster can get you referred to a more insurance-friendly doctor who will send you back to work sooner, that’s who they will send you to.
How Workers’ Comp Doctor Referrals Can Work FOR You
The good news is that, if you are aware of how workers’ compensation works, you can make your workers’ comp doctor referrals work for you.
For example, if you have a specific doctor you’d like to be treated by, such as a neurologist, you can ask your authorized treating physician to refer you to this specific doctor.
If you get the workers’ comp doctor referral in writing, the insurance company will have to authorize it.
How Workers’ Comp Doctor Referrals Can Work AGAINST You
One of the biggest issues with workers’ comp doctor referrals is that they are often general.
General referrals cause a lot of problems.
For example, your authorized treating physician will write a general referral to a neurologist instead of specifying a specific neurologist.
In this case, the insurance company is allowed to choose the doctor for the specialty appointment.
They will choose a doctor who is more likely to support them than you.
Another problem is that some unscrupulous doctors work on insurance panels and will only provide insurance-friendly referrals.
[Related Read: 10 Ways Authorized Treating Physicians Mess Up Your Georgia Workers’ Comp Claim]
The Trouble Happens When Authorized Treating Physicians Work on Insurance Panels
The problem with authorized treating physicians working on insurance panels is that they may bend to meet the insurance company’s approval.
Unfortunately, if authorized treating physicians are on insurance panels, then adjusters threaten them with removal from their panels.
These types of doctors tend to do whatever it takes to keep the insurance adjusters happy instead of considering their patients’ needs.
And what makes insurance adjusters happy? Saving money!
These doctors understand that the insurance company does not want to pay a lot of money for patient care.
As a result, these doctors will write useless workers’ comp doctor referrals or avoid referrals altogether, instead pushing long-term pain management services.
Some physicians even avoid recommending expensive tests, like MRIs or CT scans.
These doctors are not in it for patient care – they are in it to stay in the good graces of the insurance industry.
Authorized Treating Physicians Are in Charge
Authorized treating physicians are in charge of your care. Full stop.
What they say goes, and they should not worry about whether their recommendations get authorized by insurance.
If they believe you need further treatment or tests with a specialist, that’s it.
These specialists will be referred by your authorized treating physician.
Georgia law gives your authorized treating physician control over your treatment plan, which includes referring you to specific specialists.
Workers’ compensation insurance should cover it as long as your authorized treating physician refers you.
Again, no matter if these referrals are in-network or out-of-network.
You Get to Choose Your Own Pharmacy
Similarly, your authorized treating physician can write a prescription to get filled at any pharmacy you choose.
Insurance companies may try to convince you and your physician that you have to use certain pharmacies.
As a result of the insurance companies, some physicians may have your prescriptions filled at a pharmacy you didn’t choose.
Again, this is because insurance companies want to save money, so they want to refer you to budget pharmacies or those companies with which they have contracts.
The insurance company will also try to make you use a card they send you.
But, again, you can use CVS, Walmart, Injured Workers Pharmacy (IWP), etc. – any pharmacy you want!
Leave Authorization Issues up to Your Workers’ Comp Attorney
If you’ve learned anything from what I’ve shared today, it’s that insurance companies will do whatever they can to cut corners and save money – even if it means denying the treatment you need and deserve.
For instance, one of the issues we are hearing more about lately is insurance companies taking too long to authorize workers’ comp doctor referrals.
If insurance companies play games by dragging their feet with authorizations, there is a fairly new process in Georgia – the Petition for Medical Treatment (PMT). You send the referral or order to the adjuster, wait five business days for a response, and if they don’t respond, you file a form and attach supporting documents.
This results in a scheduled telephone conference with a State Board judge.
Most of the calls don’t end up happening because it forces the adjuster to either authorize or deny.
An experienced workers’ compensation attorney will recognize this delay tactic for what it is and will put a stop to it.
Workers’ compensation attorneys are also aware of the different ways insurance companies try to lower their bills, such as using in-network lies.
Working with a workers’ compensation attorney in Georgia will protect you from falling victim to greedy insurance companies.
Read More: Stressed About Workers’ Comp? Hire A Workers’ Comp Lawyer
If you’ve been injured on the job, contact us today for a free, no-strings-attached consultation.
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