Top 10 Things You Should Know About Workers Compensation Second Opinions

In approximately half the states, the employer determines the medical provider who will treat the employee for a workers compensation injury or occupational illness. In the other half of the states, the employee selects the medical provider. In many cases, the employer or the employee who did not select the medical provider becomes unhappy with the lack of medical progress by the employee. In all states the employer or employee who did not select the medical provider has the right to a second opinion. (Some times to assert this right you may have to petition the Workers Compensation Board or Industrial Commission).

1. The employer is often not kept advised by the employee or the work comp adjuster or the nurse case manager – if there is one, on the medical status of the employee. When the employer does have a work comp claims coordinator or is self-insured for work comp, the employer is much more likely to be abreast of the employee’s medical progress and known when a second medical opinion is needed.

2. Some employers have the misconception that the employee has chosen the medical provider and there is nothing they can do about it. The employer is entitled to a second opinion in regards to the employee’s medical treatment. If the medical provider is keeping the employee off work after you have offered to accommodate any modified duty restrictions the medical provider feels are justified, than it is time to request a second medical opinion. Also, if the employer is not satisfied with the medical reports and diagnosis received from the employee’s medical provider, the employer should request a second opinion, especially if the medical provider is recommending surgery or other long-term medical procedures.

3. If the employer requests the second opinion and designates the doctor for the second opinion, in most states that will be counted as one of the independent medical examinations (IME) the employer can have. For a true second opinion, and not an IME, the employer should discuss with the employee the need for a second opinion and agree to a doctor of the employee’s choice for the second opinion, if they know the second opinion doctor has the expertise and will give an unbiased report. (If the employee is represented by an attorney, the arrangement for the second medical opinion will have to be made with the attorney). If the employer does not know the doctor the employee is requesting, before agreeing to the second opinion doctor, ask the claims adjuster or local defense attorney for an evaluation on the medical expertise of the second opinion doctor.

5. In some states, the second opinion doctor will be selected by the Workers Compensation Board or Industrial Commission. When the employer and employee are located in one of these states, the employer should still pursue the second medical opinion if the employee’s recovery progress is longer than expected.
6. The second opinion medical provider should have expertise in the desired field of medicine. If the employee is treating with an orthopedic surgeon, the second opinion doctor should also be an orthopedic surgeon. If the employee is treating with several doctors, and multiple second opinions are needed, the second opinion doctors should be specialists in the appropriate fields.
7. If you do not like the results provided by the second opinion doctor, you can request a third opinion in some states. However, the employee or the employee’s attorney will probably resist a third opinion when they already have two similar opinions. If you press the matter before the Workers’ Compensation Board or Industrial Commission, you will get denied as it will appear you are doctor shopping. Remember the advice from above – know the second opinion doctor’s credibility before you agree on the doctor.
8. The cost of the second opinion doctor should be submitted to the claims office for payment. It is a good idea to advise the claims office and obtain their approval of the employee obtaining a second opinion before it happens, so that the claims office does not reject payment of the bill when submitted.

9. Some states do impose time frames on when the employer can request a second medical opinion. The time frames for a second opinion vary considerably from state to state. Some states may impose a 90 day limit after the employee starts treating, while other states will have no time limit on requesting a second opinion. The employer’s work comp claims coordinator should know the time requirements for second opinions in the state(s) where you do business.
10. Second opinions are not limited to medical treatment. If the medical provider gives the employee a permanent partial disability rating that appears excessive for the limitations the employee exhibits, an IME is justified. One area of second opinions the employer should stay out of is the recent trend for plaintiff workers’ compensation attorneys advertising they will give “free and confidential” second opinions on how the employee’s current attorney is doing in the handling of their work comp claim. The shark circling the shark……

Second opinions can be beneficial to both the employer and the employee. The second opinion can get the employee back to work that has been kept off work longer than necessary. The second opinion can often provide the employee with a different course of medical treatment that benefits the employee by providing a faster and higher degree of recovery, and benefiting the employer by returning a valuable employee to work sooner.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information.

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact [email protected].