Medical Treatment

Minnesota Workers’ Compensation Medical Treatment: Your Rights to Doctors, Specialists, Surgery and More

When you are injured at work, medical treatment is often the most immediate concern. You may need emergency care, follow-up appointments, diagnostic testing, physical therapy, a specialist, surgery, or long-term treatment.

Minnesota workers’ compensation can provide medical benefits for treatment that is reasonably required to cure and relieve the effects of a compensable work injury.

But disputes can arise over:

• which doctor you can see;
• whether you can change doctors;
• whether a specialist is necessary;
• whether surgery should be approved;
• whether a second opinion is required;
• whether an IME doctor can override your treating doctor;
• whether treatment fits Minnesota’s treatment parameters; and
• whether the insurance company can delay or deny care.

Understanding how these pieces fit together can help you avoid unnecessary delays and protect your rights.

What Medical Treatment Can Minnesota Workers’ Compensation Cover?

Minnesota workers’ compensation medical benefits can include many different types of care. Depending on the injury, treatment may include:

• emergency room care;
• hospitalization;
• occupational medicine;
• primary care;
• orthopedic care;
• neurology;
• pain management;
• physical therapy;
• chiropractic care;
• diagnostic testing;
• injections;
• prescription medications;
• durable medical equipment;
• surgery;
• post-operative rehabilitation; and
• other treatment related to the work injury.

The central question is generally whether the treatment is reasonable, necessary, and causally related to the work injury.

Hospital and Emergency Care After a Work Injury

If you suffer a serious work injury, emergency care may be necessary.

Examples include:

• fractures;
• head injuries;
• serious back injuries;
• crush injuries;
• severe lacerations;
• loss of consciousness;
• chest pain or breathing problems after an exposure;
• major burns;
• significant bleeding; or
• injuries requiring immediate surgery.

In an emergency, the priority is getting appropriate medical treatment. Workers’ compensation issues can be addressed after the immediate medical crisis is stabilized.

Hospital care may include:

• emergency treatment;
• diagnostic imaging;
• inpatient admission;
• surgery;
• specialist consultation;
• medications; and
• follow-up care.

If the workers’ compensation insurer later disputes whether the hospital treatment was work-related, that can become a medical or causation dispute.

What If I Am Hospitalized Because of My Work Injury?

Hospitalization can significantly affect a workers’ compensation claim.

It may provide strong evidence concerning the seriousness of the injury, but it can also create additional issues involving:

• wage-loss benefits;
• work restrictions;
• follow-up treatment;
• specialist referrals;
• surgery;
• discharge planning;
• rehabilitation; and
• future medical care.

After discharge, make sure you understand:

• which doctors you should follow up with;
• what restrictions apply;
• whether you are taken off work;
• whether surgery or other treatment is recommended; and
• whether the workers’ compensation insurer has authorized the follow-up care.

Do not assume the insurer automatically knows what the hospital recommended.

What Is Occupational Medicine?

Many employers direct injured workers to an occupational medicine clinic after a work injury.

Occupational medicine providers often focus on:

• initial injury evaluation;
• work restrictions;
• return-to-work decisions;
• referrals;
• physical therapy;
• medication management; and
• communication with the employer.

These clinics can play an important role early in a claim. But the occupational medicine provider is still a medical provider, not the final legal decision-maker.

If your condition becomes more complicated, you may need referral to a specialist.

Do I Have to Keep Treating at Occupational Medicine?

Not necessarily. Occupational medicine is often useful for the early stages of a claim, but it is not always the best long-term treatment setting.

Depending on the injury, you may need:

• an orthopedic surgeon;
• neurologist;
• neurosurgeon;
• pain specialist;
• psychiatrist or psychologist;
• physical medicine and rehabilitation physician;
• podiatrist;
• hand specialist; or
• another specialty provider.

If your condition is not improving, it may be appropriate to ask whether a specialist referral is needed.

Can I Choose My Own Doctor?

Minnesota workers’ compensation law generally gives injured employees important rights concerning the choice of treating health care provider. However, those rights are not unlimited. Restrictions may apply depending on:

• whether the employer participates in a certified managed care plan;
• whether you have already selected a treating provider;
• whether you are trying to change providers;
• the type of treatment involved; and
• the timing of the request.

This is one area where injured workers are often given incomplete information.

You should not assume that you are permanently required to treat with the first clinic your employer sent you to.

Can My Employer Choose My Doctor?

An employer may direct you to a particular clinic for an initial evaluation.

That does not necessarily mean the employer has complete control over all future medical treatment.

The rules concerning provider choice can depend on the circumstances.

If you are unhappy with the provider selected by the employer, or if you believe you need different treatment, it is worth determining what choices are available before simply stopping care or switching providers without notice.

Can I Change Doctors?

Sometimes, yes.

But changing treating providers can involve specific rules.

You may be able to change physicians more freely early in the claim than later.

After a treating relationship is established, additional changes may require consent or approval depending on the circumstances.

The important point is that you should not assume either of these extremes is correct:

“I can never change doctors.” or “I can switch doctors whenever I want.”

The answer depends on the facts.

What If I Want a Specialist?

A specialist may be appropriate when the injury requires care beyond what a general practitioner or occupational medicine provider can provide.

Examples include:

• orthopedic surgeons for joint or musculoskeletal injuries;
• neurosurgeons for certain spine conditions;
• neurologists for nerve or brain injuries;
• pain specialists for chronic pain;
• hand surgeons for complex hand or wrist injuries; and
• mental health providers for compensable psychological conditions.

A referral may come from your treating physician.

If the insurer refuses to authorize the specialist, that can become a disputed medical-treatment issue.

What If the Insurance Company Refuses a Specialist Referral?

The insurer may claim that the referral is unnecessary, premature, unrelated to the work injury, or inconsistent with treatment guidelines.

The treating doctor’s reasoning can become important.

A useful referral opinion may explain:

• the diagnosis;
• why current treatment has not resolved the problem;
• why specialty care is needed;
• what questions the specialist should address; and
• how the referral relates to the work injury.

If the insurer still refuses, formal dispute-resolution procedures may be available.

Do I Have a Right to a Second Opinion?

In many situations, yes.

A second medical opinion can be useful when:

• surgery has been recommended;
• you are unsure whether surgery is necessary;
• the insurer disputes treatment;
• doctors disagree about diagnosis;
• the insurer claims you are at MMI;
• work restrictions are disputed; or
• your condition is not improving.

Minnesota law also contains specific provisions relating to second opinions for nonemergency surgery.

The appropriate process depends on who is requesting the second opinion and why.

Can the Insurance Company Require a Second Surgical Opinion?

Yes, in appropriate circumstances.

If nonemergency surgery has been recommended, the insurer may request a second surgical opinion.

The insurer may also request an independent medical examination.

These are not exactly the same thing.

A second surgical opinion is generally focused on whether the proposed surgery is appropriate.

An IME may address a much broader range of issues, including:

• causation;
• diagnosis;
• work restrictions;
• need for treatment;
• surgery;
• MMI; and
• permanent disability.

What Is an IME?

An independent medical examination, or IME, is an examination arranged by the employer or workers’ compensation insurer.

The IME doctor is selected and paid by the employer or insurer.

The doctor is not your treating physician.

The IME doctor may be asked to give opinions about:

• whether your condition is work-related;
• whether treatment is necessary;
• whether surgery should be performed;
• whether you still need restrictions;
• whether your injury has resolved;
• whether you have reached MMI;
• whether you have permanent disability; and
• whether your current symptoms are caused by a pre-existing condition.

An IME can have a major effect on your claim.

But it is still only a medical opinion.

It does not automatically override your treating doctor.

What If the IME Doctor Disagrees With My Treating Doctor?

This is common.

Your treating doctor may believe you need:

• continued treatment;
• permanent restrictions;
• surgery;
• additional physical therapy; or
• more time before reaching MMI.

The IME doctor may disagree. When that happens, a compensation judge may ultimately have to decide which opinion is more persuasive.

Relevant factors can include:

• each doctor’s specialty;
• treatment history;
• objective findings;
• diagnostic testing;
• familiarity with the patient;
• factual assumptions;
• and the reasoning supporting the opinion.

A well-supported treating opinion can be extremely important.

What Are Minnesota Workers’ Compensation Treatment Parameters?

Minnesota has medical treatment parameters that provide guidelines for the treatment of certain work-related conditions.

These rules can address:

• frequency and duration of treatment;
• conservative care;
• physical therapy;
• chiropractic care;
• injections;
• diagnostic testing;
• surgery; and
• when a departure from the usual treatment rules may be appropriate.

Treatment parameters are often raised by insurers when they deny or limit medical care.

Do the Treatment Parameters Automatically Control My Treatment?

Not always.

Treatment parameters are important, but they are not simply rigid rules that resolve every case.

There can be circumstances where treatment outside the usual parameter may be appropriate.

The facts matter.

A treating physician may need to explain why a particular treatment is medically necessary even though it falls outside the usual guideline.

What Is a Departure From the Treatment Parameters?

A departure means treatment is being requested even though it does not fit neatly within the standard parameter.

A departure may be appropriate in certain situations.

For example, the treating provider may believe that:

• prior treatment was successful;
• the employee cannot tolerate another form of care;
• unusual circumstances exist;
• the employee has a complex condition;
• the standard treatment is inappropriate; or
• the proposed care is medically necessary for another supported reason.

A detailed medical explanation is often important.

Does a Denied Claim Affect Treatment Parameters?

Yes.

If the insurance company has denied primary liability and claims that the work injury itself is not compensable, the dispute is different from a simple treatment-parameter disagreement. In that situation, the main issue may be whether the employer and insurer are legally responsible for the condition at all.

The employee may need to pursue the claim through a Claim Petition rather than treating it as only a medical-treatment dispute.

What If My Treatment Is Delayed?

Delays can happen for many reasons.

For example:

• the insurer has not responded;
• the provider has not submitted the correct request;
• additional records are needed;
• a second opinion is being arranged;
• an IME is scheduled;
• causation is disputed;
• a managed care process applies; or
• the insurer simply refuses authorization.

Do not assume that a delay is unavoidable.

Find out:

• what treatment was requested;
• when it was requested;
• who received the request;
• what response was given;
• whether the insurer issued a written denial; and
• what the insurer says is still needed.

The reason for the delay determines the best next step.

What If Surgery Is Denied?

A denied surgery can be one of the most serious medical disputes in a workers’ compensation case.

The insurer may argue that:

• surgery is not medically necessary;
• conservative care should continue;
• the treatment parameters are not satisfied;
• the surgery is unrelated to the work injury;
• the condition is pre-existing;
• the IME doctor disagrees; or
• the proposed procedure is unlikely to help.

If the surgery is denied, the treating surgeon’s opinion becomes especially important.

The doctor may need to explain both:

• why surgery is medically appropriate; and
• why the work injury is a substantial contributing cause of the need for surgery.

Can I Go Ahead With Surgery If Workers’ Compensation Says No?

This can involve significant financial risk.

If the insurer has denied authorization, do not assume workers’ compensation will automatically pay later.

The dispute could involve substantial charges for:

• the surgeon;
• hospital;
• anesthesia;
• imaging;
• therapy;
• medications; and
• lost wages during recovery.

Before proceeding with disputed surgery, understand the possible financial consequences and consider obtaining legal advice.

What If My Doctor Says I Need Treatment but the Insurer Says It Is Not Necessary?

That is a medical dispute.

Depending on the circumstances, the issue may be pursued through:

• a Medical Request;
• an administrative conference;
• a Claim Petition;
• medical reports;
• deposition testimony; or
• a workers’ compensation hearing.

The correct procedure depends on whether the insurer accepts the injury and disputes only the treatment, or denies responsibility for the claim more broadly.

Can I Keep Treating After MMI?

Yes.

Maximum medical improvement does not automatically end medical care.

An employee can reach MMI and still need treatment to:

• control symptoms;
• maintain function;
• manage chronic pain;
• receive medication;
• undergo injections;
• monitor a permanent condition; or
• address future changes.

MMI is primarily about whether significant lasting improvement is still expected.

It is not the same thing as saying no more treatment is appropriate.

What About Ongoing Pain Management?

Some work injuries result in chronic pain even after the acute injury has stabilized.

Treatment may include:

• medication;
• injections;
• pain-management specialists;
• physical therapy;
• home exercise;
• behavioral health treatment; or
• other appropriate care.

The insurer may question whether long-term treatment remains reasonable and necessary.

Those disputes often require detailed medical support.

What If the Insurance Company Refuses to Pay Medical Bills?

A billing dispute can arise even when treatment has already occurred.

Possible reasons include:

• the insurer denies the injury;
• it disputes causation;
• it claims the treatment was unnecessary;
• it disputes the amount charged;
• it says another insurer is responsible; or
• it claims the treatment was not properly authorized.

Keep copies of:

• bills;
• explanation-of-benefits forms;
• insurer correspondence;
• provider statements; and
• medical records.

Do not ignore collection notices simply because the bill should have been paid by workers’ compensation.

What If My Health Insurance Paid for Work-Related Treatment?

Sometimes health insurance pays medical bills while the workers’ compensation claim is disputed.

If workers’ compensation is later found responsible, reimbursement issues may arise.

The health insurer may have an interest in recovering amounts it paid.

This can become important in litigation and settlement.

What Is a Certified Managed Care Plan?

Some Minnesota employers participate in certified workers’ compensation managed care plans.

If your claim is covered by one, the plan may affect:

• which providers you see;
• referrals;
• specialist care;
• dispute procedures; and
• how treatment is coordinated.

In some cases, the managed care plan’s dispute-resolution procedure must be used before filing a formal Medical Request.

If you are unsure whether a plan applies, ask.

What Should I Do If Medical Treatment Is Being Denied or Delayed?

Start by gathering the facts.

Find out:

1. What treatment did the doctor recommend?
2. Was the request submitted in writing?
3. When did the insurer receive it?
4. Did the insurer approve, deny, or request more information?
5. Is the dispute about medical necessity, causation, or both?
6. Is an IME involved?
7. Does a certified managed care plan apply?
8. Does the treating doctor need to provide a stronger explanation?
9. Is a Medical Request or Claim Petition appropriate?

The sooner you understand the exact reason for the dispute, the sooner you can address it.

When Should I Speak With a Minnesota Workers’ Compensation Attorney?

Consider getting legal advice if:

• treatment has been denied;
• surgery has been denied;
• the insurer will not approve a specialist;
• you are being told you cannot change doctors;
• the IME doctor disagrees with your treating physician;
• you were declared at MMI;
• the insurer claims your condition is pre-existing;
• medical bills are unpaid;
• you are being sent through repeated examinations;
• your treatment is being delayed; or
• you are unsure whether the insurer is handling the medical claim correctly.

Medical disputes can affect not only your health but also your wage-loss benefits, work restrictions, rehabilitation, and settlement value.

Minnesota Workers’ Compensation Attorneys for Medical Treatment Disputes

Lemmon & Tanasychuk, LLC represents injured workers throughout Minnesota.

We represent employees—not employers and insurance companies—in matters involving:

• emergency and hospital treatment;
• occupational medicine;
• physician choice;
• changing doctors;
• specialist referrals;
• second opinions;
• independent medical examinations;
• denied surgery;
• treatment parameters;
• delayed medical care;
• unpaid medical bills;
• maximum medical improvement; and
• workers’ compensation settlements.

If your treatment has been delayed or denied, or you are unsure what medical care workers’ compensation should be providing, we can review your claim and help you understand your options.

Contact Lemmon & Tanasychuk, LLC for a free consultation.

This article provides general information concerning Minnesota workers’ compensation law and is not legal advice. Medical-benefit rights depend on the facts of each claim and the law in effect at the time of injury.