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PA W/Comp--Can husband go see his own doctor? Pennsylvania

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  • PA W/Comp--Can husband go see his own doctor? Pennsylvania

    We're in PA.

    My husband is a sales associate, works on his feet all day (isn't allowed to sit down, except for breaks). He fell at work and injured his leg. He called in the next day and told the store manager it hurt and he needed to keep off his feet for a day. The manager said he had to come in because everyone else was out. So he went in, afraid he'd lose his job if he didn't. He worked a few days, each day the pain and limping increasing.

    Today the pain was so bad he called HR and they said he had to go to a particular hospital's emergency room in order to be covered for Workers Comp, which he did. He found out he has a hairline fracture. The attending physician gave him a work release that says he can go back to limited duties starting Thursday (not standing for any length of time, no pulling, no pushing,etc.--these are all things he's required to do for his job). Today is Tuesday and he needs to go back to work Thursday. He wasn't wrapped up in anything or put into a cast.

    Under Workers Comp law, can he go to his own doctor now (& have it covered under Workers Com) & get a 2nd opinion regarding when he can go back to work & whether he was given the proper treatment at the emergency room?
    Thanks.

  • #2
    I think you have received a good answer to this question, but here is the rule for you...
    Please be warned that, if you seek medical treatment outside the Commonwealth of Pennsylvania, you may be subject to the risk of balance billing by the medical provider. You should discuss this with your medical provider prior to initiating treatment.

    Choice of Doctor

    You are free to choose your own doctor unless the employer accepts your claim and has posted a list of six or more physicians or health care providers in your workplace, then you are required to visit one of them for initial treatment. You are to continue treatment with that provider or another on the list for a period of 90 days following the first visit. You may see any provider on the list; your employer may not require or direct you to any specific provider on the list.

    If a listed provider prescribes invasive surgery, you are entitled to a second opinion which will be paid for by your employer/insurer. Treatment recommended as a result of the second opinion must be provided by a listed provider for 90 days.

    If during the 90-day period you visit a provider(s) not on the list, your employer or your employer’s insurance carrier may refuse to pay for such treatment. After the 90 days, as well as in situations where your employer has no posted list or an improper list, you may seek treatment with any physician or other health care provider you select. You must notify your employer of the provider you have selected. During treatment, the employer or the employer’s insurance carrier is entitled to receive monthly reports from your physician or provider.

    Injured workers should be advised that your health care providers may need information concerning your claim. Some of this information may be contained in correspondence you receive from your insurance carrier, and you may want to provide copies of letters or forms to your health care provider.

    Once you begin receiving WC benefits, the employer/insurer has the right to ask you to see a doctor of their choice for examination. If you refuse, the employer is entitled to request an order from the WC judge requiring you to attend an examination. Failure to then attend may result in a suspension of your benefits.
    You can find the FAQ's for IW's in PA here....http://www.dli.state.pa.us/landi/cwp...ID=1026#doctor

    You should know that if you seek treatment from a doctor not on the list provided by the ER/IC, the cost of self procured treatment may not be reimbursed to you by your ER/IC. The ER/IC has the ability/right to control treatment, at least for the first 90 days.
    If during the 90-day period you visit a provider(s) not on the list, your employer or your employer’s insurance carrier may refuse to pay for such treatment. After the 90 days, as well as in situations where your employer has no posted list or an improper list, you may seek treatment with any physician or other health care provider you select. You must notify your employer of the provider you have selected. During treatment, the employer or the employer’s insurance carrier is entitled to receive monthly reports from your physician or provider.
    Under Workers Comp law, can he go to his own doctor now (& have it covered under Workers Com) & get a 2nd opinion regarding when he can go back to work & whether he was given the proper treatment at the emergency room?
    Choice of doctor and coverage for the cost is above, but I'm curious, if he was treated at the hospital, by the attending MD/physican in the emergency room, why would you suspect he would not be receiving the proper treatment. If your skeptisism is due to this being a comp claim, I've never seen any hospital where the ER/IC had any control over the attending physicans...
    When you are treated for a work related injury, most all treatment is subject to prior authorization through the ER/IC.
    Where the ER/IC has provided a list of Dr to select from, those Dr have agreed to treat to the adopted treatment guidelines, and accept the OMFS/Official Medical Fee Schedule. That does not in any way mean you would receive sub standard treatment....from any provider.

    You should probably consult with an attorney handling comp claims in your area. There is no fee for the consultation, and there wouldn't be a fee unless there is a award/settlement.

    Comment


    • #3
      Originally posted by CAIW View Post
      I think you have received a good answer to this question, but here is the rule for you...
      You can find the FAQ's for IW's in PA here....http://www.dli.state.pa.us/landi/cwp...ID=1026#doctor

      You should know that if you seek treatment from a doctor not on the list provided by the ER/IC, the cost of self procured treatment may not be reimbursed to you by your ER/IC. The ER/IC has the ability/right to control treatment, at least for the first 90 days.

      Choice of doctor and coverage for the cost is above, but I'm curious, if he was treated at the hospital, by the attending MD/physican in the emergency room, why would you suspect he would not be receiving the proper treatment. If your skeptisism is due to this being a comp claim, I've never seen any hospital where the ER/IC had any control over the attending physicans...
      When you are treated for a work related injury, most all treatment is subject to prior authorization through the ER/IC.
      Where the ER/IC has provided a list of Dr to select from, those Dr have agreed to treat to the adopted treatment guidelines, and accept the OMFS/Official Medical Fee Schedule. That does not in any way mean you would receive sub standard treatment....from any provider.

      You should probably consult with an attorney handling comp claims in your area. There is no fee for the consultation, and there wouldn't be a fee unless there is a award/settlement.
      When my husband went back to the hospital business service area doctor, as prescribed, this new doctor could not believe the ER said he could go back to work on Thursday. This new doctor has put him on a "no work" status and has scheduled him with an orthopaedist, an MRI and other tests to be done.
      That was why we thought his treatment at the ER was sub-standard. The attending physician said yesterday that this is how they always did ER for workers comp claims. They put you on a return to work status and then make you go back the next day to another doctor.

      Comment


      • #4
        The attending physician said yesterday that this is how they always did ER for workers comp claims. They put you on a return to work status and then make you go back the next day to another doctor.
        There is your answer... the er/emergency room doctors are not the 'treating physican' assigned to the claim...the er doctor treats to the emergency and issue the referral to the PTP...if this were a 'regular' off the street non industrial, you would see the er doctor, and be told to 'see your own primary care physican' as soon as practical...

        In WC, the ER/employER, has the ability to contor the medical in a claim for the first 90 days.

        Comment

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