Disputes are common among workers’ comp cases.
Here are the steps to take if you want a second opinion on your workers’ comp injury.
When it comes to healthcare, most Americans are used to being able to choose which doctor they see.
Even when insurance companies require you to select from their in-network providers, you typically have myriad options to choose from. So it might come as a surprise to find that the insurance company is responsible for choosing the authorized treating physician in your workers’ comp claim.
But does that mean you can’t request a second opinion?
Florida’s workers’ compensation law does provide you the opportunity to get a second opinion if you are not satisfied with the treatment your authorized treating physician is giving you. However, we don’t call it a “second opinion.” It is called your “one-time change in treating physicians.”
Maybe you feel that the doctor is siding with the insurance company rather than listening to your concerns. Perhaps you’re simply not getting any better, despite lengthy treatment. Alternatively, you might think that your doctor’s recommendations are too aggressive and you’d like to see if a gentler approach would be effective.
Whatever your reasons for considering seeking an alternate medical opinion, you are entitled to understand your rights in your workers’ comp case. In this article, we’ll explain various options available to you for getting another medical opinion from a workers’ comp doctor.
Change of Authorized Treating Physician
When you first file a claim for workers’ compensation, your employer’s insurance company likely selected an authorized treating physician for you. Fortunately, you are allowed to request a change of your physician, but do not make this decision lightly! Not only are you limited to a single one-time change in your case, but the insurance company is entitled to select your next physician as well. (There is an exception to this, which we will cover in a bit.)
Thus, there is no guarantee that your next doctor will be better, just that they will be different.
Further, your request must be made in writing and the new doctor must be in the same field of practice as your previous one. That is, if you are requesting a change from an orthopedist, your new physician will have to be an orthopedist.
In some cases, your treating physician may be the one to refer you to a specialist or to another physician in the same field for a second opinion. The insurance company will then decide whether or not to authorize the treatment. If they deny this request, an attorney can assist you with litigating your entitlement to any treatment you think you need.
Independent Medical Examiner
What happens if you have already used your one-time change request, or you don’t have an issue with the treatment from your treating physician but the insurance company won’t authorize any of their recommendations?
In this case, you can request an Independent Medical Examiner, or IME.
An IME is a doctor who serves as your expert and can provide medical opinions about your case in the event that either you or your employer’s insurance company have a dispute regarding “overutilization, medical benefits, compensability, or disability.” You can also see an IME if you feel that your workers’ comp claim has been unfairly denied.
They cannot administer treatment; rather, their job is to determine if further treatment is necessary, address what conditions you have as a result of your accident, what your work status is, or otherwise address the previously expressed opinions by your authorized doctors to determine if he/she agrees with them or not.
Both you and the insurance company have the right to request an IME. If you are the one making the request, you will have to pay for it out of pocket (although you may be able to recover the cost of same if your case is successfully litigated). If the insurance company is requesting it, they’ll be the ones to foot the bill.
Can I Choose My Own Doctor For A Second Opinion?
This is America, so you are legally permitted to see any physician you want. But the insurance company is only obligated to pay for treatment administered by a doctor of their choosing. Further, your health insurance may not cover work-related injuries.
If you decide to select your own doctor, you should do so with the expectation that you may have to pay for any and all treatments out-of-pocket.
You must also understand that that doctor’s opinions will not be admissible in your case. The only doctors that can provide opinions in your case are authorized treating physicians, Independent Medical Examiners, and an Expert Medical Advisor.
That being said, there are a few times when you will be allowed to select your own doctor:
- Your injuries are urgent and you require a trip to the E.R. or urgent care center;
- The insurance company has a “managed care arrangement” for worker’s compensation claims, in which case you may choose an in-network doctor;
- You submit a written request for a change in treating physicians and the insurance company does not provide the name of a new doctor within five days.
Who Makes the Final Decision?
As you can imagine, having the opinion of various different doctors could potentially result in multiple contradictory opinions.
If these doctors disagree about a) what your diagnosis is, b) whether it is related to your accident, c) what treatment you need, or d) what your ability to work is, the Judge presiding over your case cannot decide the issue. Instead, s/he is required to appoint an expert known as an Expert Medical Advisor or EMA.
An EMA is like an IME but, whereas an IME is selected by either you or your insurance company, the EMA is the Judge’s expert. The EMA will perform a medical evaluation, review your records, and possibly review testimony of the other physicians in the case.
After they have gathered an appropriate amount of evidence, they will resolve the dispute between the physicians. That determination is binding on all parties. As a result, you rarely end up at a trial over a medical issue.
The doctors you see following a workplace injury greatly affect the outcome of your workers’ comp case. They will be the ones to recommend specific treatment plans and make determinations about whether (and how much) you have recovered.
Because of this, the relationship between an injured worker and their authorized treating physician is very important. If you don’t feel that you can trust your doctor, a request for a one-time change in treating physician might be in order.
If you have any questions about whether getting a second opinion is the right option for you, contact the Law Office of Brian D. Tadros, P.A. for a free consultation. We practice Florida workers’ comp law and only workers’ comp law, and are not only qualified but eager to assist you with your case.