Changing an Attending Provider During an Open L&I Claim: What are the Rules?

I recently ran into issues with designating an attending provider. So, I decided to write this article to help shed some light on the topic. In L&I claims and self-insured employer claims in Washington State, the opinions of attending providers receive special consideration. Therefore, selecting the attending provider is an important decision. Can you choose your attending provider? Think you can change your attending provider? Let’s dive in and find out.

 

Attending provider – The first Step

After a work injury, to open a claim, a medical provider completes and files an initial Report of Accident (ROA) form. Many times, the provider that completes the form automatically becomes the initial attending provider. However, this designation can change.

 

First, it’s always important to remember that work injury claimants get to choose their attending provider. Sometimes, after a workplace injury, employers direct the injured worker to specific facilities. Usually, these are easily accessible urgent care type facilities. For example, Concentra, or occupational medicine divisions like Franciscan Occupational Medicine. Others include Kaiser Occupational Medicine and The Everett Clinic Occupational Medicine.

 

Choose your attending provider

People are often surprised to learn they don’t have to see these specific clinics. You can choose any attending provider you wish. The only requirement is – they must be part of the L&I medical provider network (MPN). More importantly,  you can even transfer your attending provider during the claim! Below is some important information you need to know if you want to change providers.

 

Under RCW 51.36.010(2)(a) work injury claimants covered by the industrial insurance act receive proper and necessary medical and surgical services at the hands of a physician or licensed advanced registered nurse practitioner of the worker’s own choice. With one limitation: The location of the provider must be convenient for the injured worker.

 

Change attending provider

Under WAC 296-20-065, workers can freely choose a treating provider. More explicitly, it says that “no reasonable request for transfer to a network provider will be denied”. However, there are certain exceptions. If L&I denies your request, they must notify you. The Department of Labor and Industries (L&I) must also provide a reason for denial.

 

Some valid reasons for denying a request to change a provider include:

(1) When there are other providers that can give the necessary treatment. Here, their location must be more convenient to the work injury claimant.

(2) In cases where the new attending provider fails to cooperate with L&I rules.

(3) Whenever L&I pays ongoing time loss but there’s no reasonable progress towards returning to work.

(4) When you need special treatment which is outside the license or practice of the provider.

(5) If the claim administrator says the change is appropriate but the worker refuses or delays compliance.

(6) When the qualifications of the provider aren’t suitable to treat each of several accepted conditions.

 

Bottom line

If you want to transfer to a new attending provider, L&I might deny your request. When they do, please determine whether one of the exceptions above apply. Then, if none applies, you can elevate your request up the chain of command within L&I. As always, you can also contact a workers’ compensation attorney to discuss your options.