My Workers’ Comp Medical Benefits

Medical Care & Benefits

The short answer is no; however, there are exceptions. The law states that the workers’ compensation carrier is allowed to select every medical provider you go to. If, however, they fail to respond to a request for medical care within a reasonable time, or if they deny your entire claim, you may, in some circumstances, select your own physician during the period of delay or denial. What constitutes “a reasonable time” may vary depending on the situation.

Typically, you need a need a referral from the Emergency Room physician or your Primary Care Physician (PCP) before the carrier must authorize you to see a specialist. If you can’t get a referral to a specialist, you may be able to get a referral by using your right to an Independent Medical Examination (IME). This is an expensive option because you must pay for the IME in most cases.

The statute provides for a “one-time change” in physicians during the entire life of your claim. This means you may ask for a new doctor once. When you do, your previous doctor is deauthorized and the carrier (not you) may select a new physician in the same specialty to take over your care. Be careful here. Many times you think you have a bad doctor, until the carrier sends you to one that is worse, and you find you have gone from the frying pan to the fire.

No. You can tell the doctor that you want to see the doctor alone.

The carrier and the carrier’s representatives have the right to speak with your doctors, but you have the right to see the doctor alone.

If you don’t like your doctor or don’t feel like you are making progress, you are allowed to change doctors once in your entire claim. This one-time change must be in the same specialty.
Once a doctor is authorized, you may see that doctor without “pre-authorization.”

Even though pre-authorization for a normal office visit is not required by the law, many doctors’ offices require this anyway.

Most treatment (diagnostic studies, physical therapy, injections, surgeries, etc.) do require preauthorized by the workers’ compensation carrier.

The carrier has a limited time to respond to the request for authorization. For treatment under $1,000, they must respond within 3 days; for treatment in excess of $1,000 they must respond within 10 days or they consent to the medical necessity of the treatment (which is an important burden of proof in getting treatment authorized).

Some claims (very few these days) are governed by a Managed Care Arrangement (MCA). This means there are separate rules for the delivery or medical care.

How does Managed Care differ from a regular WC Claim?

  • In most cases, you must file a Formal Grievance if you want to dispute medical care or seek authorization.
  • You may be entitled to a second opinion.
  • The carrier may be forced to pay for your IME.
  • You may be able to select your physician from a list of “in-network” medical providers.
While the statute is silent on this issue, most Judges hold that if the physician is within 50 miles of your home, you must go.

Since the carrier must pay for your transportation, they are given a fair amount of latitude on this issue.

In some cases, this can be overcome by a physical inability to make the trip, but this must be supported by medical evidence.

The carrier must provide transportation for you at their expense.

As with any specialist, this may require a referral from your Primary Care Physician.

Only in a Managed Care claim; and then, only in limited circumstances. You may be entitled to a one-time change, but even here the insurance company gets to pick your physician.

You must file a Petition for Benefits with the Florida Department of Administrative Hearings and Appeals.

A lawyer can do this for you, or you can represent yourself “pro se.”

Yes. The obligation to provide medical care extends across state lines.

Many times, you will need to help the carrier locate a physician near you.

The same rules regarding preauthorization apply.