Law
A worker who sustains an injury is entitled to such health care as may be necessary, appropriate, and sufficient as a result of his or her injury, and is entitled to make the initial choice of health professional.
The WSIB shall determine all questions concerning the necessity, appropriateness and sufficiency of health care provided to a worker or that may be provided to a worker, and payment for health care provided to a worker.
Policy
Workers may make their initial choice of health professional from among the following
- chiropractors
- physicians
- physiotherapists, or
- registered nurses (extended class)
provided that the treatment of the injury or illness is within that health professional’s scope of practice as defined in that health professional’s governing legislation.
Guidelines
Immediate or emergency health care
The WSIB recognizes that a worker’s health care needs immediately following an injury or illness may prevent that worker from choosing a particular health professional. Instead, the worker will often be treated by the first available health professional at such places as a health clinic on the employer’s premises, a walk-in clinic, or hospital emergency room.
Initial choice of health professional
In most of these cases, workers will typically arrange follow-up appointments with health professionals other than the ones providing the immediate or emergency treatment. As a result, workers are considered to make their initial choice of health professional when they obtain treatment after the immediate or emergency treatment.
For the purposes of this policy, if a worker does not obtain treatment beyond the immediate or emergency treatment, the WSIB does not consider the worker to have made an initial choice of health professional.
Management of the worker’s care
Once the worker has made the initial choice of health professional, the WSIB assumes that the worker will continue to receive care from this health professional, and that this health professional will be responsible for the management of the worker’s health care.
Treatment from more than one health professional
In some cases, a worker may need to, or choose to, seek health care from a different health professional (from among the four groups of health professionals listed under "Policy") that complements or supplements the health care already being provided by the initial health professional. For example, a worker may seek care from a registered nurse (extended class) and then seek health care from a physiotherapist for the same injury/illness.
In these cases, the worker may obtain care from the second health professional without requiring the WSIB’s authorization. However, in these situations, the WSIB expects the worker to inform
- each health professional that another health professional is also providing care, as well as,
- the WSIB.
By informing the WSIB, the WSIB can then monitor the worker’s health care treatment to ensure that the health care being provided is appropriate.
If a worker is treated by two different health professionals during the period of recovery, the WSIB will only consider one of these health professionals to be responsible for the management of the worker’s health care. Generally, responsibility for the management of the worker’s care will depend on the type of treatment, investigation, and co-ordination provided by each health professional.
Example
John begins receiving health care from a physiotherapist. Although the physiotherapy treatment helps John recover from his work-related injury, he continues to experience some pain. As a result, John goes to his family physician, who conducts a clinical assessment and prescribes pain medication. John’s physician tells him that a follow-up visit may be necessary if John continues to experience pain once he has finished taking the prescribed medication. Having visited the family physician, John continues to obtain treatment from the physiotherapist.
In this example, the WSIB would consider John’s physiotherapist to continue to remain responsible for the management of John’s health care for this episode.
If John were to continue to experience pain, and return to the family physician for further treatment, the family physician may likely pursue further investigation, such as a request for x-rays. At this point, the WSIB would consider John’s physician to be responsible for the management of John’s health care, even if John continues to receive treatment from the physiotherapist.
If a worker needs to, or chooses to, obtain treatment from more than two health professionals (from among the four groups of health professionals listed under "Policy") the worker is required to obtain the WSIB’s authorization. For the purposes of this policy, treatment from more than two health professionals is considered a change in health professionals (see the guidelines below entitled "Changing Health Professionals").
Referrals
In some cases, the initial health professional may, in addition
- to providing ongoing care, and being responsible for the management of the worker’s health care
- refer the worker to another health professional or health care practitioner. For more information on health care practitioners, see 17-01-02, Entitlement to Health Care.
In most, but not all of these situations, the WSIB would not have to authorize the referral. However, in all cases, the WSIB would expect to be informed of the referral by the initial health professional and the worker.
Example
Tom initially seeks health care from his family physician. Having assessed him, Tom’s physician refers Tom to an orthopaedic surgeon for treatment. Because this referral falls within the physician’s scope of practice, the referral and subsequent treatment can occur without the WSIB’s approval. Further, although the surgeon cares for Tom within the surgeon’s scope of practice, Tom’s family physician remains responsible for the management of Tom’s ongoing health care.
If the initial health professional can no longer care for the worker, and must refer the worker to another health professional for ongoing care, that referral would be considered a change of health professionals. In all of these cases, the WSIB must pre-authorize the change. (See the guidelines below, entitled "Changing Health Professional.")
Providing health care reports
To determine a worker’s entitlement to benefits, the WSIB expects the health professional(s) initially chosen by the worker to complete the initial reporting form.
The initial reporting form is also used the first time a chiropractor, physician, physiotherapist, or registered nurse (extended class) treats the worker, regardless of whether other health professionals have previously seen the worker.
The WSIB expects the health professional who is responsible for managing the worker’s health care to complete the WSIB’s progress reports. If another health professional or health care practitioner is also providing care, the WSIB may seek specific information from that health care provider.
Initial treatment length by chiropractors/physiotherapists
Initial treatment by a chiropractor/physiotherapist is limited to a maximum of 12 weeks. Any treatment beyond the 12-week mark must be pre-authorized by the WSIB and should be requested at least four weeks prior to the completion of the initial 12 weeks.
Chiropractic or physiotherapy treatments of more than one per day are only allowed in exceptional cases.
Changing health professionals
Once the worker chooses his or her initial health professional(s), workers are not permitted to change to another health professional without WSIB authorization. Examples in which the WSIB may authorize a change include, but are not limited to
- the worker wishes to obtain care from more than two health professionals
- the initial health professional can no longer care for the worker, and refers the worker to another health professional for ongoing care
- treatment is completed, and the worker suffers a recurrence of the work-related condition
- the initial care has been provided by a health professional or agency that is not recognized by the WSIB, or
- the WSIB has difficulty obtaining necessary information from the worker’s health professional.
The WSIB also considers a request to change health professionals if the worker
- would be required to travel a considerable distance to continue treatment with the health professional
- experiences language difficulties and finds another health professional with whom there is no language problem
- is concerned about the quality of health care attention being received, and as a result, requests a complete review by the WSIB.
The WSIB does not accept a change of health professionals if, in the WSIB’s opinion, the worker’s health care is jeopardized by the change. For example
- the requested health care treatment is unnecessary or unreasonable in view of the worker’s particular health care needs, and/or
- the interruption in the continuity of health care adversely affects the worker’s recovery.
The guidelines for changing health professionals apply any time a worker requests a change of health professional.
Changing health professionals without WSIB authorization
If a worker does not obtain the WSIB’s authorization to change health professionals when required to do so, the WSIB
- may not pay for the costs associated with that second health professional, and
- may determine that the worker is not co-operating in health care measures and may reduce or suspend the worker’s loss of earnings benefits. For more, see 22-01-03, Workers' Co-operation Obligations.
Application date
This policy applies to any choice or change of health professional made on or after January 1, 2004, for all accidents.
Document History
This document replaces 17-01-03, dated December 15, 2003.
This document was previously published as:
17-01-03, dated June 15, 1999
8.5, dated January 1, 1998.
References
Legislative Authority
Workplace Safety and Insurance Act, 1997, as amended
Sections 2, 33, 34, 37
Workers’ Compensation Act, R.S.O. 1990, as amended
Sections 50, 51
Minute
Administrative
#3, June 14, 2004, Page 368