A Few Unique Medical Considerations in a Workers’ Compensation Case

Posted on Wednesday, October 30th, 2019 at 10:08 am    

In Virginia, workers are generally required to treat with a doctor chosen from a list of doctors provided by the employer. This list is known as a “panel” of doctors. Panels must be provided for each individual specialty required.  Oftentimes, there is no time to choose from a panel because the injured worker has been transported by ambulance to the emergency room and/or undergone surgery by a physician such as an orthopedic surgeon, who will typically continue to treat the injured worker.  If the injuries are severe, there is often an extended hospital stay where the injured worker may see several specialists while in the hospital. In those circumstances, panels are not usually required, as the doctors who treat the injured worker in the hospital will typically become the authorized treating physicians by virtue of their visits with the patient and their familiarity with his or her injuries and treatment over time. 

Workers in Virginia should be wary of companies who shuffle workers off to a “company doctor” as the sole means of treating an injury. This is not in accordance with the law. The injured worker in Virginia is entitled to choose from a panel of three doctors which the employer/comp carrier must provide.  Note that all of the doctors on the panel must be from different practices. The employer cannot simply list three doctors within the same practice and ask the injured worker to choose one.   

In North Carolina, there are no panels of physicians offered. The workers’ compensation carrier is pretty much given free reign to choose a physician to treat the worker’s injuries. The thinking is that if the employer is footing the bill, they get to choose the doctor. That being said, the same kind of restrictions apply as in Virginia for Emergency treatment: The surgeons or other providers who treated the injured worker in the hospital will typically become the authorized physicians, and the carrier really does not have the right to randomly switch treating physicians just because they do not like the surgeon who performed the surgery in the hospital. 

The big difference in North Carolina is that there is a provision for a second opinion exam at the expense of the insurance company if the worker is dissatisfied with the treatment of the authorized treating physician. This must be agreed upon or ordered by the Industrial Commission. 

In Virginia, there are unfortunately no such provisions for a second opinion examinations with physicians chosen by the employee; however, workers are free to pay for their own second opinion examinations or treatment with whatever doctor they want to if they so choose, or if they are able to do so under private health insurance. That being said, workers should be cautioned that the VWCC will always give more weight to the opinions of the authorized treating physician than the injured worker’s chosen doctor. 

While the pain doctors, orthopedists, and other doctors that treat workers are of primary concern, a secondary concern is which pharmacy the employee uses and the prompt filling of prescriptions. The treating doctor is the physician who fills out the prescription. The nurse or staff for the doctor normally calls in, emails, or mails the prescription to a local pharmacy. It can be extremely frustrating for some patients when the workers compensation insurance company either delays the approval of certain medications or simply does not respond to the pharmacy’s requests for approval in a timely fashion. 

Sometimes this is based on the fact that the particular medication prescribed by the treating doctor is simply too expensive. 

 

Deciding the right medications for a worker’s condition

“According to the Insurance Journal, North Carolina authorized a study (called a drug formulary) of which drugs should be used to treat specific work injury conditions and illnesses in 2015.

“A drug formulary is, very simply, a preferred list of prescription drugs. This list can include both generic and brand name drugs, and is composed to identify drugs that are: 

(1) appropriate to treat the compensable injuries and

(2) offer good value. 

The drugs included on a formulary are considered to be medically appropriate and also cost-effective when prescribed for certain medical conditions. It is not uncommon for health care payors to maintain lists of pre-identified and pre-approved drugs. Formularies are widely considered an appropriate tool to encourage the safe and affordable use of prescription medicines.”

Supporters of drug formularies claim it saves costs and offers better medical treatments. Opponents argue that the employee may not be getting the correct drug for his/her medical condition. 

North Carolina eventually decided not to use a drug formulary. Instead they developed rules for the use of opioids for pain management.

Virginia does not use formularies, either. The authorized treating physician is free to prescribe whatever medications that he or she deems necessary to effect a cure or give relief to the patient. 

Choosing the pharmacy

Generally, while the employee in a North Carolina workers’ compensation case must use the company’s doctors, the employee can decide which pharmacy to use. The employee can also switch pharmacies if one pharmacy isn’t satisfactory. 

An alternative to visiting the local pharmacy is to use a mail-order pharmacy. For employees who can’t move about easily (workers’ compensation does not normally pay for the cost of travel to the pharmacy, a mail-order pharmacy offers the convenience of not having to leave home and saves the costs. If the carrier will not pay the costs of the medication outright, the injured worker can make a claim in North Carolina for prescription costs with a Form 25P

Often workers who have reached the point of maximum medical improvement – where additional treatments with their doctors won’t improve their condition – still need to use medications for the rest of their lives or for a substantial period of time.