Q:  If the carrier disputes extent of injury, don't we just need to have the patient file a request for a designated doctor?

A:  While designated doctors can be used to resolve an extent of injury issue, they are not always the best option for doing so...and they should never be your first choice.  There is a bit of an art to determining when to use a designated doctor and when not to. 

The best way to resolve such a dispute is for the treating doctor to obtain all of the relevant and necessary clinical and diagnostic data needed to make a diagnosis and establish a cause of injury. Sometimes a referral is necessary, like if a radiologist needs to compare pre- and post-injury MRI's to see if any additional damage or harm has occurred that was not present before an accident.

Once all of this data is collected, the treating doctor should prepare a report explaining the cause of the injury. At a minimum this report should demonstrate that the doctor understands the details of the injury event, should explain what the diagnosis is (not just give a diagnosis), and then explain how this injury could result from the injury event described. Beyond stating that the injury could be caused by the described event, this report should explain how the doctor knows, within reasonable medical probability, that this diagnosis was in fact caused by the injury event.

The opinion about the cause of injury should take into account degenerative changes and explain their significance, or lack thereof, to the causation question. If they are integral to the question of injury or cause, the doctor should address aggravation of these pre-existing conditions. Aggravation of an injury is more than a recurrence of symptoms. An aggravated condition becomes compensable only if the injury event caused additional damage or harm that was not already present.   This type of opinion must be clearly explained. Another way to say this is "how do you know this injury resulted from the event?". Give us a good medical school explanation.

Why is this the best way to handle extent of injury questions?  Because you don't know who the designated doctor is going to be in most cases. All of the usual RME suspects also serve as designated doctors.  Although theoretically the cause of injury should be determined the same by a large percentage of doctors that review the same data, we know that bias does play a role. The DWC and AMA think that a patient's impairment rating should be the same no matter who examines the patient, but we know that doesn't happen either. 

Sometimes there is no alternative and a designated doctor must be requested. This would be true if the treating doctor refuses to assist in the causation question. Unfortunately, this happens. Most employer and carrier-recommended doctors will not address causation. There are also a lot of patient-advocate doctors that will not help either. In these situations, the designated doctor is probably necessary.

Other times, this question can be manipulated. Not all extent of injury disputes arise at the very beginning of a claim. Most arise later, occasionally even around maximum medical improvement. If this is the case, it is likely that the patient has already seen the designated doctor. If so, you will already know who the designated doctor is.  More importantly, you will know the DD's opinion about diagnosis and treatment options.  If the DD report appears favorable on the question of injury and it's cause, it may be a good situation to request a designated doctor on extent of injury. Most of the time the designated doctor will hint at or state his thoughts on the issue.  Of course, this requires a detailed reading of the report and not just a glance at the end result. This method requires an educated guess at the outcome, and should not be left to clinical personnel who do not possess the education and experience to make these decisions.

Requesting a designated doctor on any issue should rarely be done without careful thought. There is nothing a designated doctor can do that a treating doctor can't do. The patient has too much at stake to gamble with the luck of the draw.

A treating doctor submitted the following question about problems he has had referring injured workers to specialists for surgical consultations.  My answer follows:

Q:  I keep having problems making referrals for orthopedic or surgical consults when taking over as treating doctor after the patient first treats at an employer or carrier-recommended facility.  That facility made a previous referral but the patient doesn’t want to continue care with these doctors. What can I do?

A:   This is a preauthorization issue.  The Official Disability Guidelines do recommend orthopedic and surgical consultations.  For a low back injury, the ODG suggests such a referral on the second visit in some cases; for a neck injury the referral is recommended as early as the first visit if there are neurological symptoms.  The issue here is not whether the consult itself is necessary.  The problem is that it has already occurred as a referral from the company doctor.

Division Rule 137.100 indicates that insurance companies are not liable for treatment that exceeds the ODG recommendations unless they are preauthorized.  The ODG allows for a consult, say for the necessity of spinal surgery, but it does not allow for two such consults.  The second consult must be preauthorized.

Most of the time, the second treating doctor makes the referral and the referral doctor can’t get the adjuster to “approve” the office visit.  Someone at the doctor’s office keeps calling the adjuster to see if the carrier will pay for the visit.  When the doctor is told no, or is ignored, the referral doctor tells the treating doctor and the patient that they can’t do the exam because it is not approved. 

The problem with this scenario is that there is no way to resolve the situation, and the patient suffers as a result.  The patient is left in limbo, often for long periods of time and there is nothing that can be done for them.  The next step in the treatment plan is usually riding on the question of surgery.

The solution to this problem is to submit a written request for preauthorization of the referral for the surgical consult.  Rule 134.600 requires the carrier to respond to this request within three business days, and send written notice of the decision within one day of making the decision.  This approach allows for the use of the IRO process to obtain the surgical consult, and a hearing after that if necessary. 

The important part of this process will be the explanation for the referral.  There should be more than a prescription pad referral.  There should be a chart note of some kind to explain the reason for the referral, ODG criteria for the referral, and the medical necessity of the referral pursuant to ODG and the doctor’s own clinical judgment.

No longer is the patient left in limbo, complaining to the doctor about the lack of treatment.  There is a decision with a defined appeals process.  There is a response for the treating doctor to give the patient when asked about status of the referral.  There’s no angst for the patient over weeks of calling the carrier with no response while they sit in pain, waiting to see a doctor.  There can be a solution other than the patient looking for a new treating doctor, one who can make a referral happen.