The New Jersey Workers’ Compensation Act provides that an employer must provide all medical treatment necessary to “cure and relieve” the effects of a work injury. The employer or its insurance carrier must pay 100% of the medical bills, with no co-payment or deductible owed by the injured worker.
The insurance carrier has the right to assign a specific physician to treat the work injury. While you may request authorization to be treated by your own doctor, most insurance carriers will not permit ongoing treatment by a personal physician. Some carriers provide injured workers with a list of “network” physicians who are authorized to provide treatment, while others direct treatment to a specific physician.
If the insurance carrier authorizes medical treatment through a particular physician and you reject that treatment, choosing instead to seek treatment with your own physician, you may be held personally liable for those medical bills.
If you fail to advise your physician that the injury occurred at work and the bills are submitted to your health insurer for payment, you could technically be charged with committing insurance fraud. The health insurance carrier may also seek reimbursement for the medical bills, to be paid out of the proceeds of any settlement or judgment you receive from workers’ compensation.
If the workers’ compensation insurance carrier denied your claim or failed to assign a physician, you may seek treatment through your health insurance. However, it is advisable to first send a formal request for treatment in writing to the workers’ compensation carrier, indicating that unless you are directed to a particular physician you will seek treatment with the physician of your choice. Preferably, you should seek advice from an experienced workers’ compensation attorney, who would serve a formal demand for medical treatment upon the insurance carrier.
An injured employee is not personally liable for medical treatment which was authorized under workers’ compensation. It is illegal for a medical provider to sue a patient for unpaid medical bills which are the subject of a workers’ compensation claim. If you are receiving medical benefits through workers’ compensation it is advisable to check your credit scores periodically, to make sure that your credit has not been negatively affected by a carrier’s failure to pay your medical bills on a timely basis. If a physician files a small claims action against you or reports an unpaid bill to the credit agencies, your attorney should forward a letter reminding the doctor that all medical bills are the responsibility of the workers’ compensation carrier and no “balance billing” is permitted under New Jersey law.
If your medical coverage is through Medicare/Medicaid, federal law provides that the parties must check with those federal programs before settling any claim, in order to determine whether the government paid any claims related to the work accident. If so, Medicare/Medicaid must be reimbursed out of the proceeds of any settlement, if the workers’ compensation carrier is not held responsible for the payment of the lien.
The short answer is that it depends upon the doctor. There are many physicians in New Jersey who have ongoing business relationships with workers’ compensation carriers, and it is their financial interest to keep the insurance carriers satisfied, to ensure the assignment of the next “customer”. Some of these physicians forget that their patient is the injured worker and not the insurance carrier. You must strive to make the workers’ compensation physician your advocate to the insurance carrier by clearly communicating your injuries and physical complaints. It may seem silly, but if your doctor likes you and believes you, he is more likely to advocate on your behalf. On the other hand, if you are a difficult patient to deal with (demanding, nasty, or seem to be embellishing your injuries), it is doubtful that a physician or his staff will go the extra mile for you. Never forget that doctors are human beings, with their own set of biases.
Even if you have an entirely unrelated prior injury to a different body part you should still inform your physician of your complete medical history. If you fail to provide a complete history you may be accused of trying to “cover-up” a prior injury. Take care though, not to over-emphasis a prior ache or pain which was not serious enough to warrant a trip to the doctor. Generally speaking, if a prior injury was not significant enough to warrant medical attention, you do not need to bring it up.
Absolutely; the insurance carrier will seek to limit or even deny a claim on the basis of a prior injury. If you sustained a prior injury to the same part of the body it is critical to obtain all medical records regarding the prior injury, to demonstrate your prior condition at the time you were discharged from treatment. Do not attempt to hide your prior injury. If you do fail to acknowledge a prior injury, you could be accused of fraud. That being said, if you disclose a prior injury for which medical treatment was sought, having a prior injury alone is not a basis upon which a workers’ compensation carrier may legitimately deny medical treatment. However, your workers’ compensation permanent disability award will be reduced by the percentage your condition is deemed to be pre-existing.
You have the right to reject any medical treatment which you do not want. However, unless you are under active medical treatment, you are not entitled to receive workers’ compensation temporary disability benefits. Accordingly, if the authorized physician recommends surgery, you should first inquire about whether less invasive measures could provide you with relief. If you have already gone through conservative treatment, such as physical therapy, medication, and/or injections, and the doctor advises that surgery is the only remaining option, then you are faced with an important decision. You may either go forward with the surgery or request a second opinion through workers’ compensation. The majority of insurance carriers will gladly schedule an appointment for a second opinion, which is much less costly than paying for surgery. However, there is a risk that the second opinion examination will be scheduled with a physician who will not truly provide an independent opinion, and will merely provide the carrier with a perfunctory report indicating that no further medical treatment is necessary.
In cases involving serious injuries, the insurance carrier will often assign a “nurse case manager,” who should not be confused with the “claims adjuster.” All workers’ compensation claimants are assigned a claims adjuster, whose responsibility is to investigate the accident, issue temporary disability benefits, direct medical treatment, gather medical records, and to negotiate the ultimate settlement of the claim. If the injuries are complex, the claims adjuster may request the assistance of a nurse case manager, who will handle communications between the injured worker, the physician, and the insurance carrier.
There are some kind and decent nurse case managers out there. However, you should never forget that the nurse case manager is a representative of the insurance carrier, and her first allegiance is to the carrier. Her goal is simply to save the insurance carrier money on the claim by limiting expensive medical treatment and facilitating your return to work as soon as possible. Therefore, you must take care when communicating with the nurse case manager not to disclose unnecessary information which may be used against you.
It is unfortunately quite common for nurse case managers to pressure doctors into prematurely releasing patients from medical treatment and/or to return to work. You may make it more difficult for the nurse case manager to put undue pressure on your physician by insisting on your right to privacy during medical appointments. Under no circumstances should you allow the nurse case manager to accompany you into the examination room during visits with your physician. The nurse case manager’s role should be limited to scheduling medical appointments and facilitating the authorization of medical testing and procedures.
The term independent medical examination (“IME”) is really a misnomer. The physician who performs such an examination is anything but “independent,” in that he is merely a hired gun of the carrier. It would be more accurate to refer to this carrier tool as a “defense medical examination.” Such examinations are often scheduled by insurance claims adjusters to provide them with the opinion that they want to hear, which is that no further treatment is necessary and/or related to the work accident.
If the carrier believes that the authorized physician is over-treating the patient, or is not returning him to work quickly enough, the carrier may choose to schedule an IME. New Jersey law gives carriers the right to schedule such examinations as often as they deem necessary. The purpose of the IME may be to direct the treatment to a more appropriate medical expert. Unfortunately though, more often than not the IME is specifically scheduled to create a basis for cutting off medical and/or temporary disability benefits to an injured worker.
Unless there is a reason to question the competence of the authorized treating physician, some workers’ compensation attorneys refuse to allow their clients to attend an IME prior to being discharged from the authorized treating physicians. The decision of whether or not to attend an IME is a strategic one. The law provides the carrier with the right to schedule these exams, and if a claimant refuses to attend such an exam his benefits may be terminated. However, if the independent medical consultant finds that no further treatment is necessary or related to the accident, the carrier may terminate further benefits on that basis anyway. If benefits are terminated following an IME the claimant’s attorney should file a “Motion for Medical and Temporary Benefits.” The Court will generally accept the opinion of the authorized treating physician, who followed the patient over a course of time, over the opinion of an “independent” expert who performed a cursory examination.
A Functional Capacity Evaluation (“FCE”) consists of a series of physical tests conducted by a therapist, to measure a claimant’s ability to perform tasks necessary for employment. Many attorneys refuse to allow their clients to attend FCEs, since the results may be manipulated and are often used to force claimants to return to work prematurely. If the workers’ compensation carrier schedules an FCE while you are still under medical treatment and has not yet been released to return to work by the doctor, there is absolutely no reason for you to attend the FCE. However, you must be aware of the dangers of refusing to attend it outright. If you refuse to attend the FCE, the claims adjuster may accuse you of failing to cooperate with medical treatment and terminate your benefits on that basis. An aggressive workers’ compensation attorney will remind the adjuster that an FCE does not cure or relieve any symptoms, so it therefore does not fall under the category of medical treatment.
In order to avoid a confrontation on this issue, if your doctor anticipates releasing you from care in 4-6 weeks anyway, another tactic is to simply reschedule the FCE until you have been medically cleared to return to work. At that point, if your employer requires you to attend an FCE in to determine your permanent work restrictions, you should cooperate with the FCE if you wish to continue working with that employer.
Whenever you appear for an appointment for authorized medical treatment you should provide the claim number of the workers’ compensation carrier, and direct all bills to be sent to that carrier. If a claim number has not yet been assigned you should provide the name of your employer. You will not be turned away at the emergency room just because a claim number has not been assigned, or if the cause of the injury is in dispute.
If you provide the workers’ compensation claim number and continue to receive bills from medical providers, you should call the billing office of the hospital or physician to confirm that the bills are being submitted to the workers’ compensation carrier. Forward the bills to the workers’ compensation carrier, with a copy to your attorney. If the treatment was authorized, the final Court Order Approving Settlement or Judgment will include a provision indicating that all bills for authorized medical treatment were paid, or will be paid by the workers’ compensation carrier.
You should not discontinue your medical treatment out of fear that your medical bills are not being paid. As long as the medical treatment was authorized through workers’ compensation the bills will be paid. It is unlawful in New Jersey for medical providers to seek payment from workers’ compensation claimants or “balance bill” them. If you receive a collection’s notice you should check your credit score to make that the outstanding bill has not been reported to the credit agencies. If the medical bill appears on your credit report then you should write a letter to the credit agencies, explaining that the bill was the responsibility of the workers’ compensation insurance carrier, and enclose a copy of the letter you received from the carrier directing you to treat with that physician, as well as the Claim Petition filed with the Division of Workers’ Compensation. It is advisable to send this information to the three major credit agencies: Equifax, Experian, and TransUnion. As of the writing of this manual, the credit agencies may be reached at the following addresses:
Equifax Credit Information Services, LLC
P.O. Box 740241, Atlanta, GA 30374
866-349-5186: Dispute Credit Report Items
Experian National Consumer Assistance Center
P.O. Box 4500, Allen, TX 75013
800-509-8495: Dispute Credit Report Items
TransUnion Consumer Relations
P.O. Box 2000, Chester, PA 19016-2000
800-916-8800: Disputes Items & Status Checks
If you are served with a Summons and Complaint, seeking collection of a bill for authorized treatment, you should immediately provide it to your workers’ compensation attorney. Your attorney should file a Motion to Dismiss the Complaint filed by the medical provider, on the basis that the issue of medical treatment is within the sole jurisdiction of the Division of Workers’ Compensation.
The medical providers also have a direct remedy against the workers’ compensation carrier. In New Jersey, physicians have the right to file their own claim for the payment of medical bills in the Division of Workers’ Compensation.
For more information on Medical Treatment Under Workers’ Compensation, a free initial consultation is your next best step. Get the information and legal answers you are seeking by calling (908) 923-0020 today.
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