Appendix DD


There will be times when you have difficulty dealing with specific members of your local medical community. What follows are some common problems and some approaches to dealing with those providers.
  1. The provider refuses to talk with your Company about an injured employee’s ability to perform regular or transitional employment. What do you do now?
    It is difficult to understand why some providers will refuse to discuss releases to regular or transitional employment. It may be that the provider is harboring some anger about a past conflict, or perhaps simply misunderstands your intention. There is a basic process to go through when dealing with providers who seem uncooperative. The general process is as follows:
    • Call the provider directly and talk with him or her about your concerns and about what your goals are for injured/ill employees.
    • If you cannot reach the provider directly, contact the provider’s nurse, case manager, or assistant to arrange either a telephone conference or a meeting with the doctor to discuss a case.
    • If you are still unsuccessful, contact the Clinic Administrator or someone else who is connected with your Posted Panel of Providers and arrange a telephone conference or direct meeting with provider.
    • While awaiting a response, you may also want to send information to the provider about your company’s Return-To-Work Program.
    • Enlist the assistance of your dedicated Claims’ Specialist.
  2. The provider refuses to release your employee to any kind of work until he or she has fully recovered from the injury. What do you do now?
    There may be any number of reasons for a provider to react this way, including a fear of employee re-injury or perhaps a long-term paternal relationship with the employee. Whatever the reason, the proper response is to follow the steps described above under No. 1, and to call or meet with the provider directly. The goal is to be sure that the provider knows you mean the worker no harm and view gradual return to work as therapeutic.
  3. The provider appears to ask the injured employee what he or she can do physically, rather than making an independent decision about physical capacities. What do you do now?
    Frequently, providers are at a loss to determine what an employee actually can do physically. Sometimes they have no idea what the employee’s job involves, or the providers may simply feel they have no way to objectively measure a worker’s physical capabilities. One potential solution:
    • Contact the provider personally and arrange an in-person meeting if possible.
    • When contact is achieved with the provider, make every attempt to understand the provider’s perspective. Your Claims Specialist may be able to suggest where an Independent Medical Examination can be obtained or where an employee may be sent for a Functional Capacities Evaluation. In many cases, this will address the provider’s concerns, while providing you with the needed information to proceed.
  4. The provider believes your Company is not working in the injured employee’s best interest. What do you do now?
    There are many situations that can result in a provider being skeptical about the intentions of an employer. For example, a provider may be suspicious of an employer’s actions if his or her previous experience was negative. Frequently, a provider has had no direct contact with an employer for many years. The proper response is to follow the basic contact process described in No. 1, and then sit down with the provider and discuss at some length the intentions of your company relative to the injured employee. It is very important that you meet face-to-face so that the provider has a real person to visualize when he or she is thinking about you as an employer.
  5. The health care provider seems to be providing unreasonable or unnecessary treatment for a work injury or illness.  What do you do now?
    The reasonableness or necessity of all treatment provided by a health care provider under the Pennsylvania Workers’ Compensation Act may be subject to prospective, concurrent, or retrospective utilization review at the request of an employee, employer, or workers’ compensation insurer. A utilization review request may be filed on a form that can be obtained from the Pennsylvania Department of Labor and Industry, Bureau of Workers’ Compensation. Remember, the utilization review process is only available for treatment provided under the Pennsylvania Workers’ Compensation Act.
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