There is often a fundamental misunderstanding among many medical providers who treat workers’ compensation patients who are injured on the job in the State of Florida, and it is wreaking havoc on workers’ compensation claims. Many times, when a physician sees a patient under a workers’ compensation claim, some of the injured workers’ complaints are ignored. This can result in an enormous problem later in the claim. If these complaints don’t show up in the medical records for months, the workers’ compensation insurance carrier may deny treatment for that area of the body which has gone untreated. This typically happens because the injured worker allegedly never complained to the physician about that particular injured body part, when in fact they did, but the physician’s office just didn’t make a note of it in the records. Of course, the people who suffer are the injured workers themselves. So, how and why does this happen?
An employee who is injured on the job in the State of Florida should report his/her injury immediately to their Employer, but must report the injury within thirty (30) days of the accident. Most do and there is no issue; however, even when you do report your injury, their are some pitfalls. Consider this:
You trip and fall at work, landing on your right side. As you fall, you try to catch yourself with your right arm, but fail. When you land, you feel a sharp, intense pain in your lower back, with pain shooting down your legs. A coworker helps you up, but your back pain is very severe. You don’t want to go to the emergency room, so your employer sends you to a walk-in clinic. At the walk-in clinic, they note your severe back pain and send you for an MRI of your lower back. You get your MRI a few days later and wait to go back to the walk-in clinic to find out the results. During this time, you notice that your right shoulder (the one you used to break your fall) is really sore and stiff. You go back to the the walk-in clinic. You immediately tell the physician that your shoulder hurts. The physician tells you, “One thing at a time,” then proceeds to focus on your back and tell you that you have a herniated disc in your lumbar spine. They refer you to a spine surgeon. Because it’s a workers’ compensation claim, the insurance carrier takes their time and gets you an appointment with a spine surgeon three weeks out. By now, you can’t really raise your right arm up all the way over your head. You are still on the muscle relaxers from the walk-in clinic, which is taking the edge of the shoulder pain as well as the back pain, so you wait it out and finally go see the surgeon.
At the surgeon’s office, you tell the medical assistant who is taking your history and your vitals that your right shoulder hurts as well. The M.A. says, “One thing at a time.” You think, where have I heard that before? The surgeon enters slaps the MRI’s up on the board and begins to tell you that you need injections and if that fails, surgery is next. You wait for an opening, and then ask the surgeon, “Can you take a look at my shoulder? It really hurts too.” The surgeon, without looking at you, says, “I’m only authorized to treat your lower back.” Then the surgeon leaves the room and you are scheduled for a follow up. Several months go by. You keep hoping that your shoulder will get better, but it doesn’t. You’ve mentioned it to the surgeon’s staff several times, but no one will look at it for you. You finally call the insurance claims adjuster. Here is how the conversation goes:
You: “The surgeon won’t look at my shoulder and its really bothering me. He says he needs authorization.”
The adjuster: “This is a back injury. The is no record of you injuring your shoulder. Why didn’t you complain about the shoulder before now? It’s been five months.”
You: “I have been complaining, but no one will listen to me.”
The adjuster: “It’s not in the records. Sorry, if it’s not in the records, I can’t authorize treatment for the shoulder after this much time.”
Result: shoulder injury DENIED.
So why does this happen? There are a several reasons, but it begins with:
THE CARRIER HAS THE RIGHT TO SELECT YOUR HEALTH CARE PROVIDERS
In Florida Workers’ Compensation Claims, the insurance carrier has a near absolute right to select all of your medical providers. As a result, insurance carriers gravitate toward medical providers who do what they ask and who are less likely to listen to their patients.
THE HEALTH CARE PROVIDERS RELY ON WORK COMP REFERRALS FROM THE CARRIER NOT THE PATIENT
When you are in private practice, you must constantly be thinking about where your business (new patients) comes from, and how to keep them coming. In workers’ compensation cases, injured workers and their lawyers have zero power to be the source of new patients. The carrier controls that. So, if the health care providers want to keep their referral sources happy (i.e. insurance adjusters and their defense attorneys), then they had better listen to them. To be fair: there are many quality health care providers out there who don’t care about the referral source being an insurance company and are happy to treat injured workers fairly, but there are those who are have completely bought into doing the carrier’s bidding and ignoring the true welfare of the injured worker.
THE HEALTH CARE PROVIDERS ARE DRINKING THE KOOL-AID
Some clinics are drinking the insurance Kool-Aid. They think they are violating the scope of their treatment authorization if they records physical complaints outside of the authorized body part (like your right shoulder in the above example). Hence, “I am not authorized to evaluate your right shoulder,” and no recording of the complaints in the record. Recently, I had a client who had a herniated disc in her neck and was supposed to see a spine surgeon, but got sent to an upper extremity surgeon (she also had a shoulder injury). When she said to the doctor, “I’m here for my neck,” he stuck out his hand and said, “I don’t want to hear about your neck, I’m here to look at your shoulder.” Unfortunately, this type of thing is all too typical in workers’ compensation cases.
If you are injured on the job, and if your physician is ignoring any of your complaints, scream Bloody Murder until you are heard. Email or fax your doctor (do not berate them, be concise and to the point) and tell them about your pain complaints in writing, and send a copy to your insurance claims adjuster. Otherwise, you may find yourself with a denial and a six month fight to get your benefits.