Preferred Health Care Providers

Choosing a doctor health careWorkers’ Compensation Attorneys Assisting Boston Employees

After falling victim to a workplace injury or illness, you should seek prompt medical care and notify your employer. Sometimes employers may enter into a preferred health care provider arrangement. Except in emergencies, this choice can affect your first medical appointment. For more information on this process, you can consult the workers’ compensation attorneys at Pulgini & Norton. A Boston workplace injury lawyer at our firm can discuss your rights and options.

Preferred Health Care Providers

Under Massachusetts General Law, Chapter 152, Section 30, a workers' compensation insurer is required to provide an employee who has suffered a workplace injury with adequate, reasonable health care as well as medicines and incidental expenses. Any reasonable and necessary costs associated with the medical care are to be paid by the insurer. An individual may be required to undergo an examination at least annually while suffering from a job-related condition.

An injured or ill employee may be required for his or her initial medical evaluation to see a preferred provider, based on an employer's election of a preferred provider arrangement. Employers are required to provide a worker with a list of the providers in this arrangement that are within the geographic area after he or she is injured. Although you need to go to that doctor first, you do not need to continue seeing that particular doctor permanently.

After the initial evaluation, you are allowed to choose your own treating physician. In Massachusetts, after choosing your first treating physician, you can switch to another medical provider once, except when a treating physician refers you to another provider in a particular specialty. In that case, you can switch once to a different specialist. After those initial switches, you can get treatment from other providers in the event of an emergency or through consent from an administrative judge.

Any employees who are required to have a first appointment with a preferred provider are to receive care as prescribed by the arrangement. However, if you are seriously injured and need immediate care, you can get immediate emergency treatment from health care providers who are not part of the preferred provider arrangement. The insurer is still required to pay all the reasonable, necessary costs of the emergency care. Also, if you ask for a health care provider in a certain specialty, and these specialties are not represented within your employer's preferred provider organization, the insurer or preferred provider organization must pay any reasonable and necessary costs. You are allowed to choose any specialist in that case.

There are regulations that cover the provision of "reasonable" and "adequate" health care services. Physicians are supposed to use the treatment guidelines, and if they do follow these guidelines, the care is presumed reasonable and adequate. When there is a material deviation from the regulations, the presumption is that it is an unreasonable or inadequate provision of health care services.

When an employer does not have workers' compensation insurance, and you receive benefits from the Workers' Compensation Trust Fund, you may be required to choose your treating physician from the Fund's choice of health maintenance organizations. However, the Fund will be required to pay all the deductibles, co-payments, and costs that the health maintenance organization that it selected requires.

Seek Advice from a Boston Preferred Health Care Provider Attorney

If you are injured or made sick on the job, you may be able to recover workers' compensation benefits. You should notify your employer as soon as possible. You also should be aware that you may be required to visit a preferred health care provider for your initial medical evaluation. At Pulgini & Norton, our workplace accident attorneys help employees protect their rights. Based in Boston, our workers’ compensation lawyers also represent injured individuals in Andover, Braintree, Waltham, and other cities in Massachusetts. Call us at 781-843-2200 or contact us via our online form for a free consultation.