Physicians: A Hassle-Free Workers’ Comp Claim Starts with You

| | Utilization Review

doctor typing on computer
When a patient presents with an injury, whether in the ER or at a private practice, the treating physician needs to know the facts about the injury. Without understanding when, where, and how the injury happened, the physician could face a costly claims dispute. If the injury takes place on a jobsite, and the patient files a workers’ compensation claim, the physician must complete the proper documentation to help ensure claims process works smoothly and efficiently. In most states, physicians must prequalify to treat workplace injuries. Upon hire, employees agree to choose an approved doctor for treatment should they be hurt on the job. For work-related injuries, physicians are required by law to refer the patient into the workers’ compensation system, whether or not the patient continues treatment with that physician.

When to Refer

When an employee gets hurt at work, his workers’ compensation insurance company should provide a list of approved doctors able to treat workers’ compensation injuries and illnesses. These doctors will have been vetted through a review process in accordance with their jurisdictions’ requirements. In an emergency, an injured employee may receive treatment from a doctor who is not on the workers’ compensation approved list. The physician must then refer the patient to an approved doctor (this procedure varies depending on the jurisdiction). States and other jurisdictions also have the option of relying on the American College of Occupational and Environmental Practice Guidelines (ACOEM), Official Disability Guidelines (ODG), state laws, or a combination of all three.

The Role of the Physician in Workers’ Compensation Injuries

A physician treating a patient for a work-related injury generally has three stages of involvement in helping the injured worker navigate through the workers’ compensation system:
  • Initial and/or ongoing treatment of the injury
  • Documentation (medical and administrative)
  • Rehabilitation
  • Return to work planning

To ensure continuity of care, a single physician will typically handle each of these three stages. Providing the best care to patients is any physician’s top priority. To achieve the best outcomes, he must also know the what, when, where and how about the injuries he treats. By knowing the administrative regulations and processes for treating workplace injuries, physicians can also help the workers’ compensation process work properly for all parties in the system.

Want more information on how to have hassle-free claims? Ask an expert today!

Zenia Cortes, MD, Orthopedic Surgeon

Dr. Zenia Cortes brings her combined expertise in sports and orthopaedic medicine to UniMed Direct, along with insights from her experience in peer and utilization review.

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