Employee Choice of Physician

Medical Benefits

Doctor taking blood pressure

Injured workers in Illinois are generally allowed to choose their own medical providers. This is limited, however, by the two-physician or chain of referrals rule.

820 ILCS 305/8(a) Illinois General Assembly | IWCC PDF; Absolute Cleaning/SVMBL v. Illinois Workers’ Compensation Commission, 409 Ill. App. 3d 463 (2011) Google Scholar | Illinois Courts PDF.

The Chain of Referrals

Under this rule, employers and their insurance companies are only required to pay for:

  • first aid and emergency medical treatment;
  • medical treatment by the first choice of physician and any subsequent treatment within that physician’s “chain of referrals;” and
  • medical treatment by a second choice of physician and any subsequent treatment within that physician’s “chain of referrals 

820 ILCS 305/8(a) Illinois General Assembly | IWCC PDF.

If follow-up care by the emergency medical provider is “extended beyond reasonable limits,” this is considered the injured worker’s first choice of physician. Bob Red Remodeling, Inc. v. Illinois Workers’ Compensation Commission, 2014 IL App (1st) 130974WC Google Scholar | Illinois Courts PDF. This is a rather new legal standard in Illinois that leaves plenty of room for argument. A single follow-up visit with the emergency provider likely does not constitute a first choice, but anything more certainly could.

Staying within a “chain of referrals” means only going to medical providers that have been recommended by a provider within that chain. For example, your family doctor might refer you to an orthopaedic surgeon, who then refers you to a pain management clinic.

It is important that every recommendation is documented within your medical records and that you keep copies of your written referrals (physician orders). These prove that you have not made a new choice of physicians.

If someone such as your attorney suggests a specialist, as long as your current treating physician ultimately makes the referral, that specialist will be considered within that “chain of referrals.” Absolute Cleaning/SVMBL v. Illinois Workers’ Compensation Commission, 409 Ill. App. 3d 463 (2011) (“the genesis of the referral has no bearing on the issue so long as the claimant’s treating doctor ultimately made the referral.”) Google Scholar | Illinois Courts PDF. Moreover, your treating physician can make a valid referral to either a specific doctor or the general medical specialty.

Panel of Physicians

The Illinois Workers’ Compensation Act contains a major exception to employee choice in the “Panel of Physicians” provision. 820 ILCS 305/8(a) Illinois General Assembly | IWCC PDF. If a “panel of physicians” has been established by an employer, injured workers can generally only treat with medical providers on this list – unless there are extenuating circumstances or a panel physician makes a referral to a provider not on the list.

Fortunately, these panels can only be established upon agreement with “the employees, or the employees’ exclusive representative,” such as a labor union, and the panel must be approved by the Illinois Workers’ Compensation Commission. 820 ILCS 305/8(a) Illinois General Assembly | IWCC PDF. The Commission’s approval is based on whether the panel is in the best interests of both the employer and the employees. Wal-Mart Stores, Inc. v. Industrial Commission, 324 Ill. App. 3d 961 (2001) Google Scholar | Illinois Courts.

Preferred Provider Program

The Illinois Workers’ Compensation Act also has another major limitation to employee choice in the “Preferred Provider Program” provision. 820 ILCS 305/8.1a Illinois General Assembly | IWCC PDF. Somewhat similar to a “Panel of Physicians,” employers can create an exclusive list of medical providers if their program is approved by the Illinois Department of Insurance. However, unlike the “Panel of Physicians,” an injured worker can choose to treat with a medical provider who is not on the list. But doing this constitutes one of the two choices of medical providers discussed above. 820 ILCS 305/8(a) IWCC PDF.

If an injured worker is treating within their second “chain of referrals,” they cannot select a new medical provider outside of that chain at their employer’s expense unless the employer agrees to the selection. 820 ILCS 305/8(a) Illinois General Assembly | IWCC PDF.

Further reading:

Elmhurst-Chicago Stone Co. v. Industrial Commission, 269 Ill. App. 3d at 902 (1995) (“Employer argues claimant’s wife recommended Dr. Bartucci first, which prompted claimant to ask his then treating physician to refer him to Dr. Bartucci. No matter how Dr. Bartucci’s name initially came up, claimant’s treating doctor still referred him to Dr. Bartucci. Accordingly, as Dr. Bartucci was in the chain of referral, employer is responsible for his medical bills.”) Google Scholar.

This article does not provide legal advice and does not create an attorney-client relationship. If you need legal advice, please contact an attorney directly.