The Doctor’s Role in Screwing Up An Ohio Workers Compensation Claim

by Dean Pavick on April 5, 2013

Armchair Doctors, Ohio Workers Compensation Claim

There have been many changes in recent years for injured workers in the Ohio workers compensation program. Many of these changes have hurt the injured worker as far as receiving necessary medical treatments and compensation benefits.One of the problem areas concerns the BWC/MCO doctors as well as treating physicians.The BWC doctors have generally become ultraconservative ,often writing unfavorable medical reviews concerning additional allowance of conditions as well as requests for additional medical treatments and procedures. Some call these medical reviewers “armchair doctors” as they never examine the injured worker and often base their medical opinions upon absurd criteria and abstract concepts. These doctors frequently appear to be adversarial in their approach to written requests from injured workers and their treating doctors, often acting like defense doctors rather than independent medical reviewers.

Part of the problem involves the treating doctors, especially specialists. Medical specialists such as orthopedic surgeons and neurosurgeons live in a world in which their recommendations and opinions are usually unquestioned. If the surgeon wants to perform elective surgery, the patient is the only person to say no. More often than not, the patient will go along with the surgeon’s recommendations. Private health insurance companies, Medicare or Medicaid will usually pay for the surgery under its fee schedule guidelines. The same is true with injections, diagnostic procedures, medications, etc. However, under the Ohio workers compensation program any type of medical treatments and procedures must be directly related to the injury and the allowed conditions in the claim and must further be necessary and appropriate. Thus, if the claim is only allowed for a knee strain, the MCO/BWC  is probably not going to authorize surgery without additional allowance of the claim for conditions which require surgery such as torn cartilage, torn ligament, or degenerative conditions such as arthritis. Surgeons usually have the patient sign a BWC  motion form and then file it with the BWC along with a diagnostic test report (i.e..MRI, CT scan, x-rays)or with an office chart note without fully explaining how the requested additional condition is directly related to the injury and previously allowed condition(s) in the claim. These specialists might be great surgeons, but they are not lawyers or have legal training regarding evidence, causal relationship requirements, and burden of proof. They have never attended an administrative hearing before the Industrial Commission or tried a case in court. As specialists, they appear to expect the MCO, BWC and/or the Industrial Commission to simply accept or rubber stamp their requests simply because they are surgeons or specialists. They thus leave the door wide open for the “armchair doctors” to shoot down their requests resulting in delays, hearings, and the potential disallowance of additional conditions and the requested treatments.If the injured worker is represented by a workers compensation attorney, these specialists and treating physicians rarely first consult with the attorney before filing motions and written requests with the BWC.

As a result, the attorney is forced to play “catch up” with the medical evidence prior to a hearing. If the necessary medical evidence cannot be obtained, the attorney may be forced to file a request to withdraw the motion or the doctor’s written request(i.e.. C-9) to avoid disallowance, and then start the process over again if the attorney obtains sufficient medical proof. In some cases, if the attorney provides the treating specialist with a background letter on the necessary medical/legal requirements and requests a report to tie everything together, that specialist might have the audacity to charge hundreds of dollars for a written report even though the attorney is trying to help the client and doctor achieve a favorable result pertaining to additional allowance of a condition and/or the treatments required for that condition which request was originally initiated by that doctor.Often, we are first contacted by an unrepresented injured worker when his/her own doctor “screws up” the necessary  written requests and the BWC medical reviewer has issued an unfavorable report triggering a hearing before the Commission. Sometimes the injured worker contacts us after he/she has attended a hearing resulting in disallowance. These latter type of cases are much more difficult to turn around and often result in permanent disallowance of a condition or the necessity of filing an appeal into the court of common pleas which is very expensive and time consuming.In an ideal world, the injured worker, the treating physician and the attorney should work together as a team to ensure a favorable outcome for the injured worker. Don’t expect the BWC doctor to advocate your best interests as an injured or disabled worker.

Pavick & Pavick L.P.A. – Law Firm
Attorney Dean G. Pavick
159 S Main St, Akron, OH 44308
(330) 253-1131 ‎

Ohio Personal Injury Attorney 
Ohio Workers Compensation Attorney

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