Photo: Lightfield Studios/Adobe Stock
In the case of City of Atlanta v. Sebastian, the Georgia Court of Appeals ruled that employers and insurers must rely on the authorized treating physician (ATP) to issue a full-duty release and suspend income benefits under Board Rule 221.
This decision highlights the importance of the ATP’s exclusive authority to determine a claimant’s ability to return to work, especially when seeking to unilaterally suspend benefits before a formal board order.
The critical consequence of Sebastian is that a unilateral suspension of benefits cannot be based on the opinion of a referred specialist alone, even if the specialist has more expertise or familiarity with the claimant’s condition than the original ATP. Defense attorneys in the practice of workers’ compensation will be the first to say this consequence has fostered inefficiency.
By way of example, just days before writing this article, I traveled to the office of an ATP, located in a nationwide walk-in clinic. In hand, I carried not one but two full-duty releases issued by specialists to whom the ATP referred the claimant.
I hoped to provide the ATP with these releases and obtain his release of the claimant, the only release that would permit the 221 suspension process. Despite contacting the ATP’s office beforehand, I was met with confusion at the office and was handed a phone number to the provider’s corporate office. I sat out in my car on the phone for more than 30 minutes.
I was placed on hold, disconnected from the operator several times and finally put in touch with someone whose solution was calling the front desk where I had just stood 30 minutes prior.
I reentered the building, trying to cut to the chase with the nurse sitting at the front desk. The ATP, I said, referred our client’s employee to two specialists, having deemed them better equipped at addressing the claimant’s only remaining issues. Both of these specialists released the claimant, and I wanted to meet with the doctor to discuss his position on the claimant’s work status. The nurse stepped away and returned a moment later. No, she said, the doctor was not willing to see me; rather, he wanted to continue to treat the claimant and come to his own determination.
As you can see from my experience, the inefficiency of Sebastian and the implications of the case stretch beyond Board Rule 221. What’s more, the decision suggests that any reference to the "authorized treating physician" within the Workers’ Compensation Act [A1] [A2] should be interpreted as referring specifically to the sole primary provider who has been designated as the ATP, not simply any authorized provider.
Under the Sebastian framework, in the WC-104 setting where the employer is attempting to convert temporary total disability benefits to temporary partial disability benefits, the ATP must directly issue work restrictions within 60 days of last examining the claimant.
Further, before an employer can offer a claimant suitable alternative employment and begin the process of suspending benefits under Board Rule 240, it must be the ATP who deems the job offer appropriate in light of the claimant’s work restrictions. In many cases, the ATP has not seen the employee in some time and will need to reassess their condition in person—yet another hurdle for the employer to overcome.
In practice, referral physicians are necessary, and workers’ compensation claims often resemble a web of referrals. A claimant may initially select an ATP based on convenience or the need for immediate treatment without fully understanding the extent of their injuries.
From there, the ATP may refer the claimant to specialists for more advanced care. In some cases, these referred physicians may become more familiar with the claimant’s condition and treatment needs than the ATP, leading to situations where the referred physician is better equipped to make key medical decisions regarding the claimant's work status.
However, despite the heightened expertise and potential greater understanding of a claimant’s injuries, Sebastian removes the teeth from a specialist’s determinations.
Therefore, it is now crucial for employers and insurers to carefully manage the treatment process and ensure that the ATP’s role is clearly defined and documented. If a referred specialist has issued a work release but the ATP has not been involved, employers should take steps to reestablish contact with the ATP and seek their opinion before taking action.
In situations where a claimant resists returning to the ATP, employers and insurers can incentivize compliance by setting up a return appointment in accordance with O.C.G.A. §34-9-202/Board Rule 202. If the claimant refuses to attend, the employer can seek to suspend benefits until the claimant complies.
If a claimant refuses to attend an initial appointment with the ATP, the employer can file a WC-PMT(b) motion compelling the claimant to confirm their agreement to attend or explain their absence. Should the claimant fail to attend a second appointment after a judicial order, benefits may be suspended under the terms of the PMT(b).
Above all, when faced with the challenges raised by Sebastian, employers and insurers should consult with legal professionals to ensure compliance with workers’ compensation laws and strategize the best approach for managing claims. With expert guidance, navigating the intricacies of workers’ compensation law remains manageable, ensuring that both employers and employees are treated fairly under the law.
Shepherd Bridges, an associate at Swift Currie in Atlanta, defends employers and insurers in workers’ compensation claims throughout Georgia.
© Arc, All Rights Reserved. Request academic re-use from www.copyright.com. All other uses, submit a request to TMSalesOperations@arc-network.com. For more information visit Asset & Logo Licensing.