WC Treatment - Self Referral

JM in ATL · June 2005

Do you allow your employees who live out of state to self refer themselves for WC injury treatments?

I have an ee who slipped and fell. We authorized his initial treatment with an MD. I now come to find out that he has been seeing a Chiropractor for his injury.

We did not authorize this treatment nor did he call to request that we authorize it.

I don't feel like we should have to pay since there were several steps he neglected to follow, including to provide a fit to work release from the Chiropractor, nevermind getting authorization.

What is your opinion on how this should be handled?

SMace · June 2005

In some states they can self refer. I would contact my adjuster and see if that is the case.

I would first try to figure out whether it was an honest mistake. Sounds like you don't have much contact with them. Maybe they weren't sure what to do. If that is the case and you deny payment, you may piss them off and they may start to milk the system. I would be careful.

If they are a pain in the butt and constantly milk situations, deny the chiropractor and stick a nurse case manager on them.

HRLASS · June 2005

We are fairly strict in our policies and communications that if an employee has a work-related injury, they must report it on a timely basis; go to our WC physicians; and any related treatments must be authorized in order to be paid. If out of town, there may be more flexibility with initial care, but treatments must always be authorized to be paid. This does not stop anyone from seeking any treatment they desire, but any time off from work is not WC and the cost of the treatment must be paid by their medical insurance, and is not covered by WC.

marc · June 2005

What was the diagnosis given in the initial, authorized treatment?

I would start there. If this diagnosis suggested a chiropractic regimen, then it is probably OK and you need the paperwork to follow. If it did not suggest this, then I would contact your WC carrier and discuss the situation with them. They will probably have a procedure or two in place to follow for this type of event.

Balloonman1 · June 2005

Some states have unauthorized medical, and you will have to pay, up to a limit regardless. Ohter states do not and the employee should be made to pay. If a WC doctor suggested chiropractor treatments over phyisical therapy I would not use them again. If a patient is referred out with out speaking to me first, I woudl not use them again.
State law will dictate, if you have to pay unauthorized medical, just blame the insurance company and use this as an educational opportunity for the employee.

The Balloonman

E Wart · June 2005

First, I would get your w/c carrier involved. They should be the ones approving treatment, etc.
Secondly in GA (if that is where this employee is housed) you should have a "hot pink" posted panel on display. You can send the employee to a doctor and then they have ONE chance to change doctors, but my understanding is it must be one of the doctors on the panel. Again, talk with your w/c provider. They should have given you the posted panel. Also, you have to be careful that you have not allowed another employee to go outside the panel. (TN now has to have a Chiro on it's panel, but not GA.)
Also, make sure you have some type of documentaiton that shows you explained the procedure for reporting a W/C injury and how they may obtain treatment. Have they ever notified you that they changed doctors or are you just getting bills?

E Wart

WC Treatment - Self Referral

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