The question, then, is what constitutes notice.  On a very obvious level, if the claimant’s counsel calls the employer’s counsel and says “I want Dr. Smith, the doctor who treated my client while the claim was controverted, to be the ATP,” I imagine that would suffice.

But what would be the effect of Dr. Smith calling the adjuster for the insurer to try to authorize an appointment?  Is that notice?  Should the adjuster be required to infer that Dr. Smith is now the authorized treating physician?

What if counsel for the claimant simply sends bills to the employer from Dr. Smith asking for payment?  Is that notice?  When does the notice take effect?  Should the employer pay for the bills?

The obvious answer is to avoid all of these questions.  The claimant’s counsel should write a letter to the employer’s counsel setting out the claimant’s intention to name Dr. Smith as the ATP.  It takes all of the guesswork out and avoids unnecessary litigation.

If your claim has been controverted and you are attempting to get medical treatment, please contact an attorney with the Ramos Law Firm.  We are here to help Georgia’s injured workers.

In a Georgia workers’ compensation claim, an employee’s personal health information can be used by the employer/insurer to assess the compensability of a claim.   Medical records are of interest to the employer/insurer because these records reveal whether an injured worker has previous injuries to the body part injured in the work accident at issue or pre-existing conditions (such as diabetes or high blood pressure).  It is critical to investigate previous injuries because the employer/insurer may not be liable for payment of medical treatment for an injury which occurred before the accident at issue and/or did not occur in the course and scope of the employee’s employment.  Additionally, if an injured worker is a diabetic or suffers from high blood pressure, these pre-existing conditions can slow down an injured worker’s recuperation or cause complications in healing.

For example, if an injured worker sustains a broken ankle and is also suffering from type 2 diabetes, but is non-compliant with her diabetes treatment plan, he or she may experience delays in her recuperation due to poor circulation or possible nerve damage in the lower extremities.  In the aforementioned example, the repercussion of non-compliance with her diabetes treatment plan can lead to serious complications, which may prevent the employee from returning to work and may sever the employer/insurer’s liability for continued medical treatment for the broken ankle.  The employer/insurer will point to this fact to deny future benefits.  Obviously, this will be a medical question for the administrative law judge.

The medical records are also a tool the employer/insurer can utilize to gather information about injured worker’s conversations with his or her medical providers.  Ordinarily, a patient’s conversation with his or her physician is confidential, however, when an injured worker files a workers’ compensation claim and seeks medical treatment for work-related injuries, the patient-physician conversations are no longer considered confidential.

Pursuant to O.C.G.A § 34-9-207, when an employee files a workers’ compensation claim, the employee waives

“…any privilege or confidentiality concerning any communications related to the claim or history or treatment of injury arising from the incident that the employee has had with any physician… .”

Employees should not be discouraged from filing a claim due to privacy concerns. The release of workers’ compensation information to non-parties is generally prohibited under the workers’ compensation code.  Employees must keep in mind that in order to receive the best medical care, the doctors must have access to his or her medical history to create an effective treatment plan.  The mutual goal of all parties is to return the injured worker back to normal duty if possible.  However, it is important to realize that this may never happen depending on the severity of the injury.  If the goal of “normal duty work status” is not reachable, then the injured worker should still strive to reach maximum medical improvement.

O.C.G.A. § 34-9-201(b)(1) provides:

The physician selected under this subsection from the panel may arrange for any consultation, referral, and extraordinary or other specialized medical services as the nature of the injury shall require without prior authorization from the Board; provided, however, that any medical practitioner providing services as arranged by a primary authorized treating physician under this subsection shall not be permitted to arrange for any additional referrals.

As the statute clearly reads, an authorized treating physician can make a referral for specialized care to any other physician.  This is not limited to the posted panel of physicians.  The only limitation is that the physician to whom the injured worker is referred may not then make another referral.  Rather, that physician must consult with the authorized treating physician for any further referrals.

The question then arises – can the employer refuse to authorize treatment from a physician who is referred by the authorized treating physician?  The short answer is generally not.  Should the employer fail to authorize treatment from the referred physician, that would certainly draw a hearing request from the claimant’s attorney.  The employer, then, would have the burden of showing that the treatment was not necessary.  Presumably, this would require opinions of other physicians to combat the referral.  Absent any such evidence, it would likely be deemed unreasonable for the employer to refuse to authorize such treatment thereby subjecting themselves to assessments of attorney’s fees.

For example, employee gets injured on the job.  She reports her injury to her employer.  Employee seeks treatment with Dr. X who is an authorized physician.  After treating with the doctor a handful of times, he recommends a test that he cannot perform.  It is recommended that the employee treat with Dr. Y in order to obtain the proper treatment which will help the employee return to work.  Dr. X files a WC-205 on December 1, 2008 to request the treatment.  Unfortunately, the employer does not respond to the WC-205.  Can the employee go ahead and treat with Dr. Y or must the employee wait for her employer to give her the authorization?

Since Dr. X was a valid referring physician and was authorized to treat the employee, the employer’s failure to reply to the WC-205 in five business days is a violation of Board Rules and justifies the imposition of a civil penalty under O.C.G.A. § 34-9-18/ Board Rule 205. It would be likely that an ALJ would impose a penalty between $100 and $1000 against the employer for not timely responding to the WC-205.  Failure to timely respond to a WC-205 causes an unfair delay when the employee is waiting for medical treatment.

One more note, if the employee went ahead and treated with Dr. Y after the 5 days passed but before the employer responded to the WC-205, the employer would be responsible for the medical expenses related to the treatment/test of Dr. Y.  Pursuant to Board Rule 205, medical treatments/tests that are prescribed by an authorized treating physician shall be paid if the treatment is related to the on-the-job injury and likely to restore the employee.

1. a Traditional Panel of Physicians;
2. a Conformed Panel of Physicians; or
3. a Workers’ Compensation Managed Care Organization (WC/MCO).

The requirements regarding what types of medical professionals are listed, how many medical professionals or medical facilities are listed differ for each type of panel.

Although the Georgia Workers’ Compensation Act has different requirements for each type of panel of physicians, the care provided to the injured worker receives remains consistent.

Quite frequently, employers utilize either a Traditional Panel of Physicians or a Conformed Panel of Physicians.  Since the WC/MCO is less frequently used by employers, very few individuals understand a WC/MCO Panel.  If an employer elects to contract with a WC/MCO to provide treatment for its injured employees, the employer must make sure the WC/MCO is certified by the State Board of Workers’ Compensation pursuant to O.C.G.A. § 34-9-208 and the corresponding Board Rule.  The application process for certification of a WC/MCO is outlined in O.C.G.A. § 34-9-208.

The State Board of Workers’ Compensation has mandatory requirements for a WC/MCO Panel.  For example, a WC/MCO Panel must have minority providers and must have the following providers listed in their Panel:

1. internists,
2. family practice,
3. orthopedic surgeons,
4. neurologists,
5. general surgeons,
6. chiropractors,
7. physical and occupational therapists,
8. psychologists or psychiatrists,
9. diagnostic pathology or laboratory services,
10. radiology services and hospital,
11. outpatient surgery, and
12. emergency care services.

Please see Board Rule 208(a)(1)(e).

The State Board also requires certified WC/MCOs annually report an updated list of providers in their network, any sanctions taken against the WC/MCO or providers in its network, reported complaints and summary of dispute resolution proceedings.  A WC/MCO’s reporting requirements provide employers and its employees with information about the providers who are providing treatment, which ensures employees receive quality treatment.

No matter which panel is chosen, O.C.G.A. § 201 requires employers post the panel in a location that is visible to all employees.  If using a WC/MCO, employers must educate employees on how to seek medical treatment when injured on-the-job.

Although the WC/MCO is quite different from the Traditional or Conformed Panel of Physicians, the State Board of Workers’ Compensation requires that WC/MCOs are certified and monitors these panels in order to ensure medical treatment rendered to injured workers remains consistent.  If you have additional questions regarding WC/MCO panels, please contact the attorneys at the Ramos Law Firm.

While providing medical benefits to the employee for a work-related injury, the employer may request examinations for the employee “at reasonable times.” This means that the employee may receive numerous notices the various appointments have been set up. These appointments can, at times seem quite inconvenient. At times the employee may not wish to appear for all of the scheduled appointments.

Failure to appear for an appointment or to cooperate with an examination can have some serious consequences. The employer, upon learning that an employee has failed to appear for an appointment can petition the Court to have the employee’s benefits suspended until such time as the employee ceases refusal of the treatment. If the Court grants the petition, the employee cannot recover any missed payments during the period of refusal of treatment. Therefore, as inconvenient as it may be, it is almost always a good idea to appear for and cooperate with any medical treatment scheduled by the employer.