Why Won’t my Doctor Accept Workers’ Compensation Insurance?

A problem that is becoming more common for injured workers in Massachusetts is finding a competent doctor who will accept worker’s compensation insurance and the medical medical-cross-3-971653-mreimbursement rates that Massachusetts’ workers’ compensation insurers are obligated to pay.  To better understand why not all doctors are willing to accept patients who have been injured on the job, one must have a grasp of how health insurance plans are written, the amount of money a workers’ compensation insurer is obligated to pay a doctor, and why it is not always in the best financial interest of a doctor to accept workers’ compensation insurance.

First, all health insurance policies have an exclusion for work-related injuries.  That means that if you are injured during the course of your employment, your health insurance policy will not pay for any medical treatment that is determined to be made necessary by your work injury.  The only exception to this rule is a situation where you are injured at work and your employer’s workers’ compensation insurer has denied payment for your medical treatment.  The workers’ compensation insurer’s denial will then trigger your health insurer’s obligation to pay for the medical treatment so long as it is determined to be treatment that is reasonable and necessary.  In this situation, your health insurer will likely then file a lien on your workers’ compensation claim if you decide to retain an attorney and file a claim at the Department of Industrial Accidents seeking to compel the workers’ compensation insurer to pay for your medical treatment.  All medical treatment made necessary by a work related injury should be billed to your employer’s workers’ compensation insurer.

Once medical treatment is determined to have been made necessary by a work injury, your medical provider then sends a “request for authorization” to your employer’s workers’ compensation insurer.  The workers’ compensation insurer’s Utilization Review (“U.R.”) company then determines whether the treatment requested by the medical provider is “reasonable and necessary.”  Once U.R. determines approves the treatment, the workers’ compensation insurer determines whether the treatment was made necessary by the work injury.  Finally, after the workers’ compensation insurer approves the treatment as reasonable, necessary and “causally related” to the work injury, your treating doctor needs to decide whether or not to accept the rate of payment offered by the workers’ compensation insurer.  In Massachusetts, the rate of payment by workers’ compensation insurers is established by the Executive Office of Health and Human Services.  These rates set by the state are often referred to as “DIA rates.”  DIA rates are very low, in most instances much lower than the rates a medical provider would be paid by health insurance, and often times even lower than what they would be paid by Medicare. Because of this, some doctors, especially those that have busy practices with patients using private health insurance such as Blue Cross Blue Shield, will refuse to accept patients who are required to use workers’ compensation insurance to pay for their treatment quite simply because they are getting paid much less to do so.

However, an increased rate of payment may be agreed upon by the insurer and the medical provider.  Most workers’ compensation insurers’ are willing to negotiate with the medical provider because they have financial incentive to do so. The higher quality of medical treatment that an injured worker receives, the shorter period of time that they are likely to remain disabled from work and receiving weekly disability payments from that same workers’ compensation insurer. So although the workers’ compensation insurer may be paying a medical provider more money for treatment than they are otherwise obligated to, they are saving money in the long run by returning the injured worker back to work sooner and reducing weekly disability payments.

Like with many issues involved with trying to navigate a workers’ compensation claim, dealing with a medical provider that will not accept worker’s compensation insurance or refusing to negotiate with the workers’ compensation insurer can be extremely frustrating.  Helping injured workers’ deal with the process of getting medical treatment approved and paid for is another service that our Massachusetts workers’ compensation attorneys can assist with, and we do so without any additional fees associated with this service.  Please contact us today with any questions regarding this issue.