In Pennsylvania, there are specific regulations governing how injured employees can access medical treatment following a workplace accident. It is crucial to understand these rules, including the “90 day rule” under § 306 of our state’s Workers’ Compensation Act.
For the first 90 days of care after your injury, care must be provided by a “panel doctor” for it to be covered. Your employer chooses this list of doctors (usually with advice from their insurance carrier). Care can only come from care providers outside of this list under certain circumstances.
For help with your Workers’ Comp case and help navigating these rules, call Cardamone Law’s Certified Pennsylvania Workers’ Compensation Lawyers at (267) 651-7945.
What is the 90 Day Rule for Workers’ Comp Medical Care?
Under the 90 day rule, your care has to come from doctors chosen by your employer for the first 90 days, known as “panel doctors.” If you do use outside care, it will not be covered. Failing to cooperate with or follow through with the care recommended by these panel doctors could lead to suspended or terminated benefits.
The First 90 Days
In the first 90 days, any care you get should come from a panel doctor. You can usually find the list of approved doctors in your workplace on a poster or list somewhere. You can also check with your employer or their insurance carrier.
Most panel lists include doctors to cover most general care you would need, but talk to a lawyer about using specialists outside of this list.
After 90 Days
You and your Pennsylvania Workers’ Compensation lawyer will have the freedom to choose any healthcare provider you want after the first 90 days. Care should be covered as long as it is recommended and carried out by a practitioner with a Pennsylvania license to practice.
Exceptions for Outside Doctors Under the 90 Day Rule
There are a few exceptions where you can go “off list” and get care with a different physician covered.
Surgery Second Opinions
If your panel doctors say you need surgery, you can get a second opinion from a doctor of your choice outside of the list. If this second opinion suggests a different treatment plan, your doctors might change their plan or continue to say you do, in fact, need the surgery. If you do go through with the surgery, it still must come from a panel doctor.
If the panel doctors reject the second opinion and you refuse the surgery, your benefits could be suspended or terminated. However, we may be able to fight to get that requirement overturned before a Workers’ Comp Judge (WCJ).
Specialists
If you need a specialist who is not listed on the list of panel doctors, you can seek treatment from outside specialists of your choice. For example, many doctors on the panel list are general practitioners, so-called “Workers’ Comp doctors,” chiropractors, and physical therapists, with at least one surgeon usually listed.
If you need a neurologist, orthopedic surgeon, or other specialist who is not on the list, you can choose what specialist to use.
Who Can Be Included on an Employer’s List of Panel Physicians in Pennsylvania?
Under the 90 day rule, an employer’s list of panel physicians must include at least six designated healthcare providers.
Physicians
At least three of the listed doctors have to be physicians, i.e., medical doctors (MDs) or doctors of osteopathic medicine (DOs). Psychiatrists (as opposed to mental health therapists or psychologists) are also licensed as MDs. These are all what you traditionally think of as “doctors.”
The rest can be other medical professionals, like physicians assistants (PAs), nurse practitioners, chiropractors, physical therapists, sports medicine professionals, etc. Many of these might even be the kind of medical professional you would see at a hospital or as your primary care provider, even if they are not “doctors.”
Coordinated Care Organizations/Workers’ Comp Doctors
Among these panel providers, no more than four may be a coordinated care organization. These are sometimes called “Workers’ Comp doctors,” as they specialize in treating work-related injuries.
Workers’ Compensation lawyers notoriously hate “Workers’ Comp doctors,” as they are not always licensed as physicians, and they might not have the relevant medical experience or training to truly treat your injuries. It is always good to look skeptically at coordinated care organizations.
Other Licenses Allowed
As mentioned, not all of these care providers are going to be “doctors,” but they typically must all be licensed in Pennsylvania. That might include licensure as a
- Nurse
- Physician’s assistant
- Chiropractor
- Acupuncture or traditional medicine professional
- Sports medicine professional
- Physical therapist
- Mental health therapist (LPC, LSW, LCSW, MFT, etc.)
- Occupational therapist
- And more.
No Conflicts Allowed
It is important to note that the employer is prohibited from including any healthcare provider or physician owned, employed, or controlled by the employer or their insurance company unless such a relationship is disclosed on the list. This ensures transparency and impartiality.
However, the employer is still the one who chooses these doctors and ultimately pays for the treatment (through their insurance carrier), so there is always some level of conflict and possible suspicion behind who these doctors “really work for.”
Switching After 90 Days
As soon as you can choose your own care provider, it might be in your best interests to do so. If you are happy with the care you are receiving, it might be fine to continue with the panel doctors rather than losing continuity of care, but the choice of doctor is yours.
Changing the List
An employer has the discretion to modify their list of panel physicians. However, any changes made must still adhere to these requirements.
Differences Between Panel Physicians and Personal Healthcare Providers in Pennsylvania
As mentioned, panel physicians are healthcare providers chosen by your employer’s insurer to offer medical treatment for the first 90 days after a work-related injury.
Panel Doctors
In terms of treatment, panel physicians are often focused on providing immediate care to address the harm you suffered. Their approach may prioritize getting you back to work as soon as possible, and they may fail to recognize the true extent of your injury.
Your Doctors
Your personal healthcare providers, however, may have a more comprehensive understanding of your medical history, pre-existing conditions, and overall healthcare needs. Their treatment approach may look more at the full picture of your health and medical history, as they consider not only the immediate injury but also its potential long-term impacts on your health and well-being.
They may ultimately advocate for you better than a panel doctor would.
How Are Panel Doctors Different from IME Doctors?
Panel doctors may be chosen by your employer, but they are very different and serve a different role from the “Independent Medical Exam” doctors you will have to see.
Treating Physicians
Your panel doctors are your “treating physicians.” These are the doctors determining your care plan and actually carrying it out. They are paid by your Workers’ Comp carrier, but any doctor you use to treat your work injuries would be paid that way.
IME Doctors
An IME doctor is very different. They are not there to care for you, but to gather information about your condition and use it when making determinations about
- Whether to accept or deny your treatment
- What injury or illness to list on your claim
- Whether you have reached Maximum Medical Improvement (MMI) or whether ongoing care is unnecessary
- Whether you are, in fact, disabled.
Role in Your Case
When your case goes before a WCJ, the WCJ needs medical reports to make their decision about your disability and care needs.
This IME doctor wholly serves the Workers’ Comp insurance carrier and wants to shut down your case to save their employer. Their reports to the WCJ will usually say as much.
Our lawyers often need to seek outside medical exams and doctors’ reports to counter the evidence provided by the IME doctor.
FAQs for Using Panel Doctors in a Workers’ Compensation Claim
Is it Safe to Use a Panel Doctor?
These physicians all need to be licensed medical professionals, whether they are licensed as “physicians” or some other professional. It should be safe to use them, but you should keep on your guard about what you say to them and be on the lookout for any suspicious care or shortcomings.
Review everything with your lawyer, especially if it sounds suspicious.
Can I Talk Freely to My Panel Doctors?
You should not disclose more information than necessary for treatment. Talk to your lawyers about what you should and should not say to the panel doctors, as they will often report back to the insurance carrier.
Can I Choose My Own Doctor if I’m Unhappy with the Care?
For the first 90 days of care, you cannot use your own doctor of choice unless there are serious issues or conflicts with all of the doctors on the list. However, you can potentially switch to a different doctor on the list.
After 90 days, you can choose your own care providers. Many injured workers will be on Workers’ Comp for a long time, so the first 90 days might ultimately be a short portion of your treatment.
Are ER Visits Covered?
If you have to go straight to the emergency room after an injury, worry about getting treatment ad getting better instead of worrying about which doctors you are using. We can seek to get the care reimbursed later.
If you go to the hospital straight from work, they may direct you as to what hospitals or care providers to use. As soon as you are able to check in with a lawyer and the insurance carrier, you can start using an approved panel doctor.
Can I Get a Different Doctor “Panel-Approved”?
No. Only your employer can put doctors on their panel list. As an employee or Workers’ Comp claimant, you usually get no say over the doctor until after the first 90 days.
What if the Doctors Are Too Far Away?
If you live far from where you work, you may be able to use other doctors closer to where you live. However, employers often choose doctors with a wide coverage area so that their doctors will always be close enough to any injured workers.
Our lawyers can always help you choose doctors and get the care you need, so talk to us about whether these providers are too far away.
Call Our Law Firm for Assistance with Your Workers’ Compensation Claim in Pennsylvania
If you sustained a work-related injury, get support from our Certified Philadelphia Workers’ Compensation attorneys by calling Cardamone Law today at (267) 651-7945.
