If you’re receiving workers’ compensation and disagree with your treating physician’s diagnosis, treatment plan or return-to-work recommendation, you have options.
The law provides a structured process for disputing medical opinions, but timing and procedure are critical. Here are some beneficial steps to take in exercising your rights.
Request a second opinion through a QME
In California, if your claim is accepted and you disagree with your treating doctor, you may request a second opinion from a Qualified Medical Evaluator (QME). A QME is an independent physician certified by the Division of Workers’ Compensation (DWC) to resolve disputes.
You must submit a QME request form within 10 days of receiving the doctor’s report. If you miss the deadline, the claims administrator will choose the QME.
Understand the role of reviews
If your doctor recommends treatment that’s denied by the claims administrator, the denial must go through a utilization review (UR). If the UR rejects the treatment, you can appeal through an Independent Medical Review (IMR). This process is designed to ensure that treatment decisions are based on medical necessity, not cost alone.
Know your rights if your condition is misclassified
If your injury is misclassified, you may not receive appropriate care or benefits. For example, it may have been labeled as a strain instead of a more serious condition, necessitating additional or different treatment.
In such situations, a QME reassesses your diagnosis and determines the correct level of impairment. This helps preserve the workers’ compensation benefits you truly deserve.
The workers’ compensation system can be complex and time sensitive. Experienced legal guidance can improve your odds of a successful outcome.