Which Doctor: City Of Atlanta v. Sebastian and Navigating the System of Authorized Treating Physicians
By: Shepherd Bridges
In City of Atlanta v. Sebastian, the Georgia Court of Appeals affirmed a reinstatement of a claimant’s income benefits and, in doing so, placed a spotlight on the critical role the authorized treating physician (ATP) plays in unilaterally suspending indemnity benefits.
Following a work injury, Sebastian selected his ATP, who, in turn, referred Sebastian to a spine specialist. After the specialist released Sebastian to return to full duty work the employer/insurer unilaterally suspended his income benefits.
However, the court determined unilateral suspension of income benefits under Board Rule 221 required the employer/insurer rely on a full duty release from the ATP, not merely any authorized physician, such as a referral physician. Thus, the unilateral suspension of Sebastian’s benefits was improper as it was only supported by the release of a referred specialist.
Sebastian underscores the exclusive authority of the ATP in providing work releases which can support a suspension of benefits prior to a Board Order. Thus, employers must understand they cannot rely on the work status reports of referred specialists to unilaterally achieve this objective.
But, the implications of Sebastian may reach beyond Board Rule 221 as the decision suggests all references to “the authorized treating physician” within the Workers’ Compensation Act refer to the primary authorized provider, i.e. the ATP, not just an authorized provider.
Under such an interpretation, the ATP must directly issue work restrictions within 60 days in order to initiate the process of converting temporary total to temporary partial disability benefits under Board Rule 104. Further, the ATP must deem an offer of alternative employment suitable to a claimant’s restrictions for an employer to offer such suitable work and begin the process of suspending the claimant’s TTD benefits under Board Rule 240.
Unfortunately, the practical framework for treating work injures relies heavily on the referral process. A claimant often selects their ATP based on the availability of immediate treatment and without knowing the nature and extent of their injuries. This initial provider identifies the pertinent conditions and treatment, and, if appropriate, refers the claimant to specialists best equipped to handle the required treatment. Such situations frequently arise in which the referral provider becomes far more versed in the claimant’s condition than the ATP, is far better equipped at determining a claimant’s treatment needs/disability and/or essentially serves as the claimant’s sole medical provider following the referral.
But under Sebastian, even where the more informed referral physician, with an established history with the claimant, issues a full duty release, employers must seek a carbon-copy opinion from the ATP to comply with the law controlling unilateral suspension. Oftentimes, however, getting a claimant back to the ATP can prove difficult. The claimant may be hesitant to return to an ATP who can affect their continued receipt of income benefits. Additionally, the provider may be reluctant to see a patient referred to a specialist or render an opinion regarding a patient they have not personally examined for months or longer. Thus, it is helpful to know how to navigate the claims where such issues arise.
It is important to remain cognizant of the details regarding a claimant’s treatment, immediately identify the actual ATP and ensure such designation is documented. If a referral physician performs the bulk of a claimant’s care, consider seeking the claimant’s consent to designate this physician as the new ATP and file a WC-200a to memorialize the change. No agreement? File a WC-200b/Request For Change of Physicians to secure an Order to designate the referral physician as the ATP.
If a referred physician already issued a work release, the demands of the case warrant returning the claimant to the ATP. If you anticipate the claimant may be reluctant to return, the employer/insurer can incentivize compliance with a return appointment. For example, the employer/insurer can set the return appointment pursuant to O.C.G.A. § 34-9-202/Board Rule 202 and provide timely notice and mileage to compel attendance. If the claimant fails to attend the appointment, the employer/insurer can then seek suspension of indemnity benefits until the claimant returns to the ATP. Alternatively, if the claimant fails to attend a properly noticed appointment with the ATP, the employer/insurer can file a WC-PMT(b), which will force the claimant to confirm their agreement to attend or explain the missed appointment. If the claimant agrees or the ALJ issues an order to attend and the claimant then misses the second appointment, the PMT(b) will permit a judicial order to suspend indemnity benefits.
Additionally, it is worth noting the implications of Sebastian are not all detrimental to employers and insurers. In many instances, the imbalanced authority between ATPs and referred physicians is beneficial. For example, only an ATP is authorized to issue a permanent partial disability impairment rating for a claimant under Board Rule 263. Furthermore, as O.C.G.A. § 34-9-201 makes abundantly clear, only the ATP is authorized to issue referrals – thus negating a potentially nauseating and endless chain of providers and a game of leap frog for the right to suspend benefits.
For better or worse, the ATP plays the central role in a claim for workers’ compensation. Therefore, it is critical to assure a clearly defined and efficient relationship between claimants and their selected ATPs.
Attorney Contact Info
Shepherd Bridges
shepherd.bridges@swiftcurrie.com
404.888.6127