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In Oregon, injured workers are allowed their choice of attending physician. They may select an initial attending physician and change physicians two additional times. Insurer or Workers’ Compensation Division (WCD) approval is required for more than three worker choices.
Who qualifies as an attending physician under Oregon workers’ compensation?
Generally, medical doctors, doctors of osteopathy, and oral and maxillo-facial surgeons can qualify as attending physicians. Nurse practitioners may treat an injured worker for up to 90 days and authorize time loss for 60 days as an "attending physician". As of January 2, 2008, WCD certified chiropractors, physician assistants, podiatrists and naturopaths may treat for a cumulative 60 days or 18 visits and authorize time loss for up to 30 days. Medical services may continue after the 60 or 90-day limitation if the treatment has been authorized by a medical doctor or osteopath and carried out under a treatment plan. An "emergency room" physician is limited to authorizing 14 days of time loss unless they continue to treat the worker on an ongoing basis in a clinic setting. If a worker is enrolled in a Managed Care Organization (MCO), the MCO may designate other specialties of medical providers to assume the attending physician role.
Responsibilities of an attending physician
The attending physician is an important role within the workers’ compensation system. Here are the three primary responsibilities associated with the attending physician’s role:
- Is primarily responsible for your treatment and care
- Authorizes time loss
- Monitors, directs or approves ancillary and specialized care by other providers
Can I have more than one attending physician at a time?
Generally, the injured worker may only have one attending physician at a time. Occasionally, separate specialties of care are required based on the worker’s medical condition. Treatment by more than one specialty should be coordinated by one physician and documented in writing for the insurer.
Choice of attending physician
Documentation on who is the attending physician at a given time will be determined by evaluating the facts and documents in the claim to assess whether it was a worker choice or not. Generally, a form 827 changing the attending physician will be reviewed to determine if it was a worker choice. In the absence of a signed form 827, the facts of the claim may help determine whether it was a worker choice to change physicians. Each claim is different.
These situations do not qualify as a worker change of physician choice:
- Emergency services by a physician;
- Examinations at the request of the insurer;
- Consultations or referrals for specialized treatment or services initiated by the attending physician or authorized nurse practitioner;
- Referrals to radiologists and pathologists for diagnostic studies;
- When workers are required to change medical service providers to receive compensable medical services, palliative care, or time loss authorization because their medical service provider is no longer qualified as an attending physician or authorized to continue providing compensable medical services.
- Changes of attending physician or authorized nurse practitioner required due to conditions beyond the worker’s control. This could include, but not be limited to:
- When the physician terminates practice or leaves the area;
- When a physician is no longer willing to treat an injured worker;
- When the worker moves out of the area requiring more than a 50 mile commute to the physician;
- When a worker is subject to managed care and compelled to be treated inside an MCO;
- A Worker Requested Medical Examination;
- Whether a worker has an attending physician or authorized nurse practitioner who works in a group setting/facility and the worker sees another group member due to team practice, coverage, or on-call routines
- When a worker’s attending physician or authorized nurse practitioner is not available and the worker sees a medical provider who is covering for that provider in their absence.
What happens if I am enrolled in a Managed Care Organization?
A worker who has been enrolled in an MCO is usually restricted to a MCO-panel attending physician. However, even if your physician is not a member of the MCO panel, the MCO can authorize your primary care physician to provide medical services for you if you are an established patient. Your physician must be a general, family practice, or internal medicine physician and agree to the MCO’s terms and conditions for providing medical services. If your physician qualifies under one of these medical specialties, the insurer will notify the MCO. Your attending physician must abide by the terms and conditions of the MCO in order to continue your treatment.
You are not required to change attending physician if you are being treated by a physician immediately after a surgical procedure (usually no more than 90 days) or if you believe it would be medically detrimental for treatment of your accepted condition. If you have been advised to change physicians and do not agree with the insurer’s request, contact the insurer to discuss your concerns.
If you have been enrolled and need to change attending physicians, it is important to do so as soon as possible. Your current attending physician may be able to assist you in selecting a new physician. Failure to change physicians in a timely manner may affect your benefits.
I received a billing for medical services – what should I do?
If your claim has been accepted, you should not incur any out of pocket expense associated with medical services related to your claim. You should contact the medical provider to make sure they know you have filed a workers’ compensation claim. If you have purchased medications for your injury, submit your receipts to your insurer for reimbursement. You may utilize the form located here to submit your request: http://www.cbs.state.or.us/external/wcd/policy/bulletins/docconv_9540/3921.pdf
Occasionally, you may be required to pay for medical treatment. Your attending physician should notify you at the beginning of treatment under what conditions you would have to pay for medical care. Here are some examples of when you will be responsible for payment:
- Treatment for conditions not related to the accepted compensable injury or illness
- Treatment that has not been prescribed by your attending physician
- Palliative care (a medical service that makes you feel better but doesn’t heal a medical condition) after your claim has been closed without obtaining prior approval from the insurer or the Workers’ Compensation Division
- Treatment from a doctor who is not a member of a managed care organization (MCO) panel after you have been enrolled by the insurer in an MCO
- Treatment after you have been notified that the treatment is experimental, outmoded, unscientific, or unproven
Questions?
The Office of the Ombudsman for Injured Workers was established as an independent advocate for Oregon’s injured workers. We are here to help you with any question or concern you may have regarding your claim.
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