Injuries Case Studies: Janet Works Thesis

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Refusal to cooperate with the physician selection on the part of the employee could result in a termination, cancellation or simple refusal of benefits.

This physician, the first to treat the patient regarding the work related injury for which the claim is filed, is known as the physician of record. The physician of record has certain duties and obligations to both the patient and the other parties concerned with the worker's compensation claim. Their primary concern is, of course, the treatment of the condition that caused the claim, and the general health of their patient. As part of this treatment, the physician of record has the responsibility to determine the extent of the disability, as well as the date on which the employee can safely return to work. Their report can also allow for further treatments, such as physical therapy. In addition to treating the patent, the physician must keep the insurance carrier apprised of any significant changes in the patient's condition, especially those that might affect the employee's ability to work or otherwise alter the status of the claim.

This leads to one of the controversies surrounding worker's compensation: the right to medical privacy. The federal HIPAA Privacy Rule and almost all state medical privacy laws allow or even require that a patient's worker's compensation files containing their protected health information be made entirely available to review by the insurance carrier claims adjusters and the employers. Normally, such information cannot be distributed to anyone without express written consent of the patient, and indeed most laws make it clear that other pre-existing conditions with which the patient is diagnosed or for which they are treated cannot be disclosed to employers or insurance carriers. The implications for this exception to the medical privacy rule reflect a general distrust not only of the worker filing a claim based on a workplace injury, but even a certain mistrust of the physician of record. The only purpose behind the insurance review of medical documents in this case would be to make sure that no fraudulent claims are being made, which could only occur if the physician was involved in some level of conspiracy with the patient.

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The fact that it is the government that is at financial risk of fraud in worker's compensation instances might have something to do with the way the law allows for full disclosure of protected health information in these instances, but does not allow it in other insurance claims.

The employer's responsibilities during the claims process are to file the proper notifications within the time frame provided for by state law, though sometimes it is the physician who files this "first report of injury." This time span can be anywhere from twenty-four hours to ten days after receiving written notification from an employee claiming a workplace injury. After receiving this first report of injury, the insurance carrier must then determine whether or not the injury is covered by worker's compensation rules. If it is, then the insurance carrier notifies the employer with an Admission of Liability. Any wage compensations due to the patient are mailed by the insurance directly to the worker. In addition, all medical bills are submitted directly to and paid by the insurance carrier. if, however, the insurance carrier finds that the injury does not fall under the events covered by worker's compensation, they will file a Notice of Contest, and the employee becomes responsible for their medical bills. If a claim is denied or terminated, the worker may appeal, first through mediation, then through successive levels of the state's courts, eventually going so far as reaching the state's supreme court or the worker's compensation board, depending on the state. If at any point it is determined that the claim was justified, the employee will receive compensation for any medical bills already paid in addition to back wages they are entitled to......

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