The development of networks that mandated injured workers go to a doctor in that employer's network was a significant success for cost containment. This eliminated many private doctors from being able to see injured workers as some networks were virtually impossible to gain inclusion into. Moreover, if a doctor did not adhere to the conservative insurance approach to healthcare, their request for renewal was declined.

About this same time, the Official Disability Guidelines (ODG) were implemented and enforced by the insurance carriers and eventually accepted as the standard by the Texas Department of Insurance.

As a result of these two changes to the Texas workers' compensation system, the insurance companies have collectively saved hundreds of millions if not billions of dollars in cost containment. Make no mistake about it, at the end of the day, insurance companies are lucrative private businesses.

How does this relate to the subject of disputes of a claim? Well the most common reason for a dispute or denial of healthcare services is based on these two factors: doctor network exclusion and exceeding ODG treatment recommendations.

A common insurance determination is to dispute the claim as not occurring in the scope of work, often termed relatedness. Even more common is to agree to a simple (and cost effective) sprain/ strain injury but to deny all other clinically supported and identified injuries, termed an extent of injury dispute. For example, if treatment is begun and the doctor's impressions include sprain/strain as well as a disc injury that may require surgery, often the insurance will accept the simple sprain and determine the disc to be pre-existing and denied for relatedness or extent of injury.

The best way to fight these tactics is to insist on choosing a doctor (and lawyer if necessary) that is both familiar with workers' compensation and willing to devote the time necessary to properly fight for your right to all healthcare required. Fortunately, disputes are usually overturned if you and your healthcare team are both patient and persistent. Remember you do have the right to choose your doctor.

Texas Administrative Code 408.021 states that injured workers in the state of Texas have the right to any and all healthcare that promotes, relieves or cures the naturally occurring effects of the occupational injury.