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Workers’ Compensation: Does The Insurance Company Pressure Your Doctors?

A Canadian newspaper recently reported serious accusations — workers’ compensation doctors were pressured to provide opinions so claims could be denied. The Canadian paper printed the story as if it were unusual. It’s not. We see it every day. It’s the sad reality of a compensation system full of claim managers with a goal other than helping injured workers recover. These claim managers know how to find biased doctors who will help with their goal.

Most injured workers hope to recover quickly. They want to return to their jobs and their normal lives. Instead, they often face unnecessary delays in treatment as well as biased caregivers. Their calls to the insurance adjuster go unanswered and unreturned. Imagine needing medical care and having your calls ignored for weeks. That’s the reality faced by many injured workers. These problems have become an epidemic for our system.

In the workers’ compensation system, medical providers face tremendous pressure from insurance companies. It’s unjust. And, it’s at every level of medical care.

PRESSURE STARTS WITH THE GATEKEEPER PHYSICIANS

What is a “gatekeeper physician.” I use this term for the company’s initial occupational doctor. Usually, it’s a doctor or clinic performing many medical tasks for companies. These include pre-employment physicals, drug tests and initial post-injury examinations. Here, we will focus on post-injury examinations.

These gatekeepers have a clear goal — keeping medical costs low. How do they keep the insurance carrier’s medical costs low? They do several things. Here are two primary tactics:

  1. Gatekeeper doctors create a pre-existing condition argument — For more discussion about pre-existing conditions and workers’ compensation claims, you can read some of my prior articles. Briefly, the key issue in Alabama is whether or not you could perform your job fully without problems when you suffered your accident. Gatekeeper physicians sometimes ignore that issue. Instead, they actively look for prior problems. If you hurt your back in a work-related accident, these doctors will search for prior back problems — no matter how remote. If you had a prior condition (even if it has not bothered you in years), these gatekeepers may magnify it to make you look bad. If you had a past problem in the same bodily area as your current injury, you should seek legal advice. And, if that prior problem resolved, did not affect your work, or was worsened by the current accident, you need to be clear with the gatekeeper doctors.
  2. Gatekeeper doctors ignore the problem — This is a standard approach for gatekeeper doctors. Consider a typical back injury. Many back injuries resolve with time. Gatekeepers know that. However, serious back injuries do not. For workers with a significant injury, ignoring the patient’s complaints can sometimes make costly claims go away. How? Some patients tire of complaining to the doctor. They give up. They decide to live with the problem or seek care outside the workers’ compensation system. Some patients are ignored for so long doctors can no longer relate their condition to the accident because so much time has passed. Some patients experience a later event or accident outside work. Then, the gatekeepers blame that event instead of the work-related accident. If you have suffered an injury, you need to be consistent and persistent in your complaints to the physician. You need to request a specialist. And, if you get no results, you need to seek legal advice.

CONTROL APPLIES TO TREATING SPECIALISTS

In Alabama, the workers’ compensation insurance company picks your treating doctor. Most specialists care deeply about their patients. But, a few do not. And, these few doctors face financial pressure. Pressure to ignore you. Pressure to say you are exaggerating. Pressure to not provide costly care. Pressure to release you (even if you are still hurting). This is another issue where experienced legal counsel can help. Over many years, we have dealt with most of the specialists in northern Alabama. We know who generally listens to their patients. We know who generally does not help their patients. A biased medical specialist can leave you with unresolved injuries impacting your life, your work and your compensation claim.

BIAS CONTINUES FOR THE FINAL IME DOCTOR

At some point, the treating doctors will conclude you have reached maximum medical improvement (MMI). That’s an important milestone. I’ve discussed the significance of MMI in prior posts. When you reach MMI, the issues of permanent restrictions, impairment ratings and future treatment needs, may all be important. Insurance companies know they can save tremendous costs at your expense by getting a biased doctor to issue opinions on these issues. These opinions can greatly affect any permanent disability benefits owed you. These opinions can also greatly affect any future care provided. A few physicians actually make their living creating biased reports for insurance companies. It’s wrong and unjust. And, you should seek advice before seeing a biased IME doctor.

Doctors should be allowed to provide you needed medical care without outside pressure. Unfortunately, that outside pressure exists. While most doctors focus on their patients, a few do not. You need to understand the system. If you are facing any of these issues, you need to seek experienced legal advice.