Workers’ compensation claims hinge on a doctor’s report from an authorized medical care provider within the workers’ comp insurance network. When you disagree with your primary treating physician’s (PTP’s) assessment, you don’t have to accept their report as final.If you disagree with your doctor’s diagnosis, treatment plan, or disability assessment, you can generally request a second opinion, third opinion, or an independent medical review (IMR). Of course, every state comes with different rules and requirements. To get the most out of your claim, it’s important to understand how a second opinion works in a workers’ compensation case.
One-Time Request for a Different Primary Treating Physician
When you apply for workers’ compensation benefits, you are usually assigned to a primary treating physician (PTP) by the workers’ comp claims administrator. After the first appointment, you can select a different physician within the same medical provider network (MPN) or health care organization (HCO) approved by the Division of Workers’ Compensation (DWC). In California, if you predesignated your personal doctor for work-related injuries, you could also seek treatment from them, per the Department of Industrial Relations (DIR).If you have not predesignated your doctor and your employer does not have an MPN or HCO, the claims administrator will assign a doctor for your first 30 days of treatment. After 30 days, you can choose a different physician. Certain limitations apply, so it can help to consult with a workers’ comp attorney before you switch medical providers.
Request a Second or Third Opinion Within the Same Organization or Network
After you switch to a new doctor, you may disagree with their diagnosis, disability assessment, or treatment plan. Workers’ compensation disputes like this are extremely common. Your PTP’s medical evaluation and utilization review (UR) are critical for a successful workers’ compensation claim, so it is reasonable to request another opinion if their assessment keeps you from getting benefits or the treatments you need.
Second Opinion Process for Workers’ Compensation
If you disagree with your PTP’s injury assessment or treatment plan, you can request a second or third opinion from another doctor within the same MPN or HCO. To file the request, you must:
- Advise your claims administrator or employer that you disagree with your PTP’s opinion, either orally or in writing
- Choose a second physician from the DWC’s list of approved MPN providers
- Schedule an appointment with the new MPN provider within 60 days
- Advise your claims administrator or employer of your second or third opinion appointment date
If you disagree with the second opinion physician’s treatment or diagnosis, you can follow the same process to request a third opinion within 60 days of the second opinion.When you tell your employer or claims administrator you want a second or third opinion, they must provide a regional list of MPN providers, advise the current PTP of your request, and provide case details to the second or third opinion physician. A workers’ compensation lawyer Los Angeles can ensure that you receive everything you need to submit a timely second opinion request.
What a Utilization Review Means for Your Claim
Your employer and workers’ comp administrator determine if your doctor’s recommended treatment is necessary through a utilization review (UR) process. The UR process is highly regulated and must be consistent with medical guidelines, labor codes, Medical Treatment Utilization Schedule (MTUS) regulations, and DWC requirements. In some cases, the claims administrator will deny your treatment plan based on the UR process. This UR decision can prevent you from receiving the medical treatment you need.
Submit a Request for Independent Medical Review
If you disagree with the second or third opinions or if the claims administrator denies your treatment plan in a UR decision, you can request an Independent Medical Review (IMR). (DIR)During IMR, a licensed physician with an independent medical review organization examines all your claim documents to determine whether the requested treatment is medically necessary. You must submit an IMR form and a copy of the UR decision to the independent medical review organization within 30 days of the UR decision. The claims administrator will provide all the related documentation to the IMR administrator. However, you can send your own supporting documents and any new information.A workers’ compensation lawyer can help you compile and submit documents to support your IMR request within the required time frame.
Appeal an IMR Determination With the Workers’ Compensation Appeal Board
If the IMR determination is not in your favor, you have a final option to appeal the decision. You must submit an appeal to the Workers’ Compensation Appeals Board (WCAB) within 30 days of the IMR determination mailing date. To qualify for an appeal, you must provide clear and convincing evidence of:
- Administrative overstep
- A material conflict of interest
- Discriminatory bias
- Erroneous mistake of fact
If your appeal is successful, the WCAB will reverse the final determination and assign your IMR to a different medical reviewer. If not, the IMR determination is final, and you will need to seek other avenues for compensation. A workers’ comp attorney can advise you of other options through State Disability Insurance (SDI) or potential legal action. (Employment Development Department)
How a Workers’ Compensation Attorney Can Help You With a Second Opinion
When you are injured on the job, a workers’ compensation claim covers medical expenses, lost income, disability, and vocational rehabilitation so you can recover and live a productive life. Employers and workers’ comp insurance carriers often try to minimize workers’ comp settlements. As a result, workers’ compensation claims are frequently underpaid or unfairly denied. A workers’ compensation lawyer can help you understand your legal rights following a workplace injury. They can help ensure that your doctor accurately documents your condition, and they can advocate for the benefits you deserve. If you have trouble with the treating physician, your attorney can help you take the next step to get a second or third opinion by:
- Gathering evidence to prove the cause of your injury
- Documenting how your injury affects your ability to work or engage in normal daily activities
- Ensuring that you complete and submit all necessary documents by the required deadlines
- Actively advocating for your right to workers’ comp benefits in meetings, negotiations, hearings, and correspondence
- Holding your employer, claims administrators, and doctors accountable for meeting workers’ compensation deadlines
When you are recovering from a debilitating workplace injury or illness, a workers’ comp lawyer can provide invaluable knowledge and resources.
Consult With a Workers’ Compensation Lawyer Today
Learn more about how a second opinion works in a workers’ compensation case with a consultation at KJT Law Group. Our dedicated workers’ comp attorneys can review your claim and help you determine the best way forward. Contact our office today or call (818) 507-8525 for your free consultation.