When Have You Violated The Two-Physician Rule?

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When Have You Violated The Two-Physician Rule?

An employer’s liability to pay for medical services selected by the employee is governed by Section 8(a) of the Illinois Worker’s Compensation Act. It states, in relevant part:

“The employer’s liability to pay for medical services selected by the employee shall be limited to:

  1. all first aid and emergency treatment; plus
  2. all medical, surgical and hospital services provided by the physician, surgeon or hospital initially chosen by the employee or by any other physician, consultant, expert, institution or other provider of services recommended by said initial service provider or any subsequent service provider of medical services in the chain of referrals from said initial service provider; plus
  3. all medical, surgical and hospital services provided by any second physician, surgeon or hospital subsequently chosen by the employee or by any other physician, consultant, expert, institution or other provider of services recommended by said second service provider or any subsequent provider of medical services in the chain of referrals from said second service provider.”

To translate, you have your initial emergency medical treatment and your choice of two subsequent medical providers. If you need more than two medical providers for the treatment of your work-related injury, it is necessary for those providers to come from within your chain of referrals. For example, let’s say you initially go your family care physician for treatment. You then have a falling out with your doctor and establish yourself at a new clinic. Let’s further say that the second doctor recommends you undergo a course of physical therapy and refers you to a particular therapist. If you decide to go with a different therapist and make an appointment on your own, your choice of therapists will not be covered under 8(a) because he will be considered your third choice of providers, and therefore in violation of what is referred to as the “two-physician rule.”

What is not considered “your choice” of physicians? Doctors chosen by the employer are never considered to your selection. Doctors chosen by the employer are typically either doctors that are located on your employer’s premises or are an employee of your employer or a clinic selected by the employer without asking you for your preference.

First aid and emergency treatment do not count as an employee’s physician choice. Let’s say you sustain a deep laceration while operating an electric saw. This would be a situation requiring immediate and emergency treatment. You go to the Emergency Room at your local hospital and receive sutures and anti-biotics. That ER doctor is not considered your first choice of physicians, because they are emergency treatment. You then report back to your employer following the ER treatment, and they set you up with an appointment for a family care physician in the area, who is not your regular doctor. Although he is not considered emergency treatment, the employer is liable for his medical services because that doctor was their choice. Following the chain of referral logic, any subsequent providers coming as a referral from that family doctor are still not considered to be your choice, even if the employer did not influence your subsequent treatment.

Aside from our initial example, what are some other ways an employee can violate the “two-physician rule”?

Following the latter example, after having gone to the emergency room and having been scheduled an appointment with the family care physician of your employer’s choice, you decide to skip that appointment and go back to the emergency room for a refill of your pain medications. Would that second trip to the emergency room be considered your first choice of physicians? Yes, it would. Although you went to an “emergency” facility, you didn’t go for a bona fide emergency. You had the option of maintaining your appointment with the family care physician, although not your choice, and could have obtained your pain medication from him. Now, had your sutures ruptured, that would be completely different, as it would necessitate the need for emergency treatment.

It is noteworthy to add that if you are knowingly outside of the rule, you are generally not able to choose which of your physicians are to be considered your first and second physician choices. To illustrate, you cannot seek treatment from several doctors and submit the bills of those providers who were for the greatest amount. Thus, seeking reimbursement for your fourth and fifth choices of physicians simply because they were for surgical intervention and therefore larger, is not consistent with the Act.

If you have suffered a work injury and seek any clarity regarding whether or not your medical treatment will be covered, please contact our office immediately.