Slim Pickins

They say you can't find good help these days and nowhere is that more true than when it comes to finding specialists who will agree to accept a workers’ compensation patient.  

I'm not talking about occupational medicine or orthopedics. Those are pretty common and most of us don't have any problem finding a physician in those specialties.

But once in a while, you'll have an unusual claim which requires a specialist that is very hard to find in the world of workers’ compensation. Oncology, cardiology and pulmonology specialists may be available in your area, but that doesn't mean they're going to agree to accept a worker's compensation patient. Why would they want to do all that extra work when the reimbursement rate is limited?

So, what is a claims administrator to do if you have an unusual claim where cancer, cardiovascular or pulmonary issues are compensable, and your injured worker needs access to treatment?

The answer is pretty straightforward: it's time to pony up some dollars. If you find yourself in this situation, you can enter a specific agreement with a specialist where you agree to pay a pre-negotiated (and usually ABOVE fee schedule) rate so that they get the reimbursement that they are seeking in exchange for providing treatment to the injured worker. If you do go down this road, do not make these decisions alone, especially if you have never drafted a letter of agreement before. Reach out to your excess carrier, and ask for assistance in identifying the desired specialist as well as drafting the letter of agreement. Since excess carriers are much more familiar with high severity claims, there's a good chance that they have seen this before and may already have a specialist in mind as well as the understanding of what rates that specialist will accept to treat a patient.

Physicians who will usually sign to a letter of agreement are typically not in network, and they may not agree to provide the specific reporting you would expect to see for your state. In fact, you may need to go to an IME to actually determine things like permanent disability and apportionment. But they can provide treatment, and you'll need to make sure the injured worker has access to treatment before they can even cross the bridge to the issues of permanent disability and apportionment.

So yes, it is hard to find good help these days, but that doesn't mean you have to do the searching alone. Excess carriers, nurse case managers and brokers should all be part of your team to help identify the specialists you need so that injured workers can get the care they need.