By Donna Motley, Vice President of Claims

An Occupational Clinic plays a very important role in the world of Workers’ Compensation insurance. An Occupational Clinic differs from an Urgent Care Clinic. The treating personnel at Occupational Clinics, primarily, if not exclusively, treat work related injuries.

Work injuries greatly differ from an injury that may occur at home or result from a motor vehicle accident. Think about machine shops, foundries, stamping plants, etc. and all the equipment utilized to manufacture product within those facilities. Even a restaurant kitchen exposes an employee to more hazards than would be encountered at home. Work injuries can affect virtually every part of the human body (and we have seen it all!).

Occupational Clinic personnel “specialize” in work injuries. We encourage you to develop a close working relationship with your chosen Occupational Clinic. Invite a physician or therapist from your Occupational Clinic to tour your facility so they can see the type of work being performed; so they are familiar with the type of injuries that may occur; and thereby also aid them in determining whether or not the injured worker can return to work with restrictions. Most Occupational Clinics are very familiar with the rules governing Workers’ Compensation and attempt to treat accordingly. The personnel know a disability slip is required for an employee to provide to his employer. Occupational Clinics generally know authorization for testing is required prior to scheduling.

Some Occupational Clinics retain specialists on staff. These specialists are at the clinic a couple days per week, as well as having an independent office/practice outside of the clinic. This aids Workers’ Compensation in that the injured worker can be seen at the clinic by a “specialist” and/or immediately referred to the outside office of the specialist, thereby expediting the process.

Personnel at the Occupational Clinics are familiar with our Nurse Case Managers, enabling our Nurse Case Managers to be able to call and obtain an appointment “stat” for an injured worker, either at the clinic or the physician’s private office. Our Nurse Case Managers know what day of the week a physician performs surgery. The Nurse Case Managers are familiar with the physician’s office staff which aids in obtaining medical information or passing a message to the physician.

The role of an Urgent Care Clinic and a hospital Emergency Room is to “stabilize” the patient and “refer the patient to their Primary Care Physician”. An injured worker treating with a Primary Care Physician can be one of the worse things they can do. Not that the treatment would be inferior, but because the physician is not familiar with Workers’ Compensation Rules. When treatment for a work injury is provided by a Primary Care Physician, HIPPA (Health Insurance Portability & Accountability Act) comes into play. HIPPA, a Federal Law enacted in 1996, restricts access to individuals’ private medical information. Workers’ Compensation must then first obtain a signed Release from the injured worker/patient before we can obtain any medical records from the Primary Care Physician. While we are waiting for medical records, Workers’ Compensation benefits, or authorization for treatment, are put on hold, which delays treatment and recovery.

Workers’ Compensation is not governed by HIPPA; the rule is: if you are going to bill us for treatment, then the medical records are “mandatory”. Primary Care Physicians generally will not bill Workers’ Compensation. We have had some indicate they don’t want to be “involved” with all the “rules”.

Payment for any treatment under Workers’ Compensation is governed by the Michigan Health Care Services Rules. A physician or facility can charge whatever they want, but payment is determined and set by the Michigan Fee Schedule. So whether treating at an Occupational Clinic, Urgent Care or Primary Care Physician office, payment would be the same. (Which is why some facilities and/or physicians do not accept Workers’ Compensation patients.)

The Health Care Services Rules will not pay for unnecessary treatment. Guidelines are established to control “reasonable & necessary”.
Should a claim be litigated, the treating physicians are deposed and must defend their diagnoses and practices.

No one benefits from an employee obtaining inferior medical treatment. The goal is to have appropriate medical care in a timely fashion so the injured worker can resume their normal lifestyle. The Occupational Clinic physicians realize when a medical condition is beyond their expertise and will readily refer to an outside specialist when appropriate (usually after conservative treatment has failed).

Medical treatment plans are followed by our office and we will voluntarily move the injured worker to a specialist if we feel recovery is not progressing. Also, if an injured worker expresses concerns about lack of progress, we will refer to a specialist.

After an employee injury, the employer should check with the employee periodically to see how treatment is progressing. Once the employee has returned to work and has been discharged from doctor care, the employer should still follow up with the employee a couple times to make sure they are having no further issues. If there are concerns or issues, our department should be informed. We are just a phone call away!