(Ed. note: I worked on an a separate appeal on this case, albeit with a different date of accident and a different Carrier.)

The number of Carriers contracted into a manage care plan has dwindled over the years.  However, there are still some left and if you are a claims professional or Employer still associated with such a managed care plan, it is important to understand all of the legal “wrinkles” in your plan. 

For one, section 440.134 works hand-in-glove with s. 440.13 and with this most recent case it is important to understand there can be two opportunities for a Claimant to choose a change in doctors. 

In McNealy v. Verizon, Claimant already utilized a change in doctors within the orthopedic specialty. She then filed a new PFB seeking a authorization of a PCP.  This claim was already years old and Claimant stopped treating with her initial PCP in lieu of long term treatment with her specialists.   The E/C denied the claim on the grounds that the current ortho specialist was also the PCP and therefore a PCP is no longer medically necessary.  The Judge agreed. 

This seemed like a simple, correct ruling.  How can a Claimant get two choice of doctors beyond just the one time change mandated in s. 440.13(2)(f)?   Well, according to the managed care statute, s. 440.134(6)(c)10 and Florida Admin Code, Rule 59A-23.003(7)(i), a Claimant–under a managed care arrangement–gets to not only choose his PCP, but allowed to get a change in PCP.

The First DCA reveresed per these rules, as well as the Carrier’s own managed care plan which mimiced the statute and Rule.   The medical necessity of the PCP change is irrelevant.  Claimant has a statutory right to choose her PCP.  

Although, the Court did not address it, I assume this ruling could allow a Claimant two choices in PCP’s if she did not get an initial choice at the outset of the claim.  Yet, I know most managed care E/C’s at least offer Claimant a choice of 3 PCP’s to seek initial care.

What to take away from this: be sure to document what care is initially offered to Claimant.  If a choice is offered, document all of the doctors offered and (if possible) have Claimant sign off on her choice.   All E/C should also calculate exposure on settlements for a change in PCP should Claimant not made the change or had the opportunity to choose her PCP.