It’s a Two-Way Street: When Physicians Won’t Provide Basic Information About Their Treatment
We recently received a question from a client involving a common fact pattern: a treating physician provides a medical record and bills for treatment, but the medical record is silent on some important element – like a statement relating the treatment to the occupational injury. Requests to that physician to clarify his opinion on causation do not garner any additional information. Does the employer and the insurer have any remedy in that situation? The answer is: “yes” – the employer may legally withhold payment of the physician’s bill under these circumstances.
Va. Code §65.2-714(A) concludes with the following sentence: “No physician shall be entitled to collect fees from an employer or insurance carrier until he has made the reports required by the Commission in connection with the case.”
The question, therefore is “what reports are required by the Commission in connection with a case” to satisfy §65.2-714(A)?
A Commission decision from 2000 provides important context on this issue. In Foti v. Arlington County, VWC File No. 110-34-74 (March 24, 2000), the Commission discussed the issue:
[Claimant] argues that the reporting requirement of Code § 65.2-604 applies only to existing medical records, and that the provider is not obligated to make reports at the request of the employer or carrier. We disagree.Code of Virginia Sec.65.2-604 requires that an employee’s treating physician shall, upon request of the employee, the employer, or the insurer, furnish a copy of any medical report to the injured employee, the employer, or the insurer or to each of them on request for such a medical report. Gardner v. Legum Home Health, 74 OWC 97 (1995) An employer responsible for the costs of medical treatment is entitled to medical records and reports that show the nature of the treatment being provided, the current status of the claimant, and the relationship of the treatment to the work injury. Hardy v. Augusta Correctional Center, VWC File No. 151-08-12 (September 28, 1995) (citing Va. Code § 65.2-604). The Commission may require reports not requested by other federal and state agencies and medical codes are not sufficient to report medical diagnosis and medical services. Martin v. Saunders B. Moon Community, 71 O.W.C. 198 (1992). If such reports are not forwarded, the employer is entitled to withhold payment to the health care provider. Jenkins, Sr. v. Lowe’s of Norfolk, Inc., 59 O.I.C. 149 (1980).
Foti, at 6-7. The Commission has also made clear that this applies not only to initial statements of causation. Employers have the right to seek out and receive a statement that ongoing treatment remains related to the occupational injury. See, eg, Chapman-Swann v. Marriott Corporation, VWC File No. 134-36-98 (September 20, 1996), (“Although the Commission has found that the psychiatric treatment is causally related to the compensable injury, a workers’ compensation carrier is nonetheless entitled to review treatment progress notes to assess the continued reasonableness, necessity, and causal relationship of the ongoing treatment.”)
Our advice in dealing with recalcitrant physician is to send a copy of the Attending Physician’s Report form to the provider and ask them to complete it, with specific attention to the information that has not been provided. In the case of our current question, a statement of causation. The Attending Physician’s Report contains spaces seeking information about most of the basic facts or opinions that carriers require to be able to follow and evaluate the treatment. A clear statement that the information is necessary for your processing of their billing and that without this information, payment will not be made is also a reasonable way to urge compliance.
Treating physicians receive a great deal of deference from the Commission as to their treatment of the claimant, but there are limits to that deference. The employer and insurer’s right to obtain essential information from the treating physician is entrenched in statute as well as case law. Withholding payment for medical treatment is often a risky proposition and can result in sanctions when done for improper reasons, but it is a recognized remedy you may use to enforce your right to be informed about the treatment for which you are being asked to pay.
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