To overcome the disagreements on an MPN doctor’s treatment plans with a claims administrator, an injured worker has the option to induct another physician on the MPN list.

The injured worker can also solicit additional opinions from different MPN physicians. In case the disagreement still lingers on, then he must select an Independent Medical Review (IMR) to resolve the dispute after studying the information provided by the employer.

By contributing a slew of services, the DWC Medical Unit is doing exemplary work ineffectively doling out medical benefits under the workers’ compensation system.

Going beyond framing the policy and guidelines for the treatment and evaluation of injured workers, the medical unit exerts a big say in the appointment of physicians in the role of qualified medical examiners or QMEs.

The QMEs play a vital role in determining the benefits that come to injured workers on the basis of their eligibility.

The Medical Unit undertakes certification of medical groups treating the workers such as medical provider networks (MPNs) and healthcare organizations (HCOs).

The medical unit facilitates utilization review (UR) plans and settles UR complaints by working with the Audit Unit.

The medical unit carries the responsibility for independent medical review (IMR) and independent bill review (IBR). These tools go a long way in solving disputes on medical treatment and medical-legal billing.

Support is also extended to the DWC administrative director for easing bottlenecks that bother providers in the compensation system including medical fee schedules, and medical care.

Disagreements exist with MPN doctors on issues beyond diagnosis or treatment, including the timing of returning to work after the treatment. To address that problem, the worker must move a request seeking the appointment of a QME.

If an injured worker disagrees with the denial or modification of a treatment plan, he must start the IMR process by sending the signed form in the relevant envelope that may also carry the determination letter that denied or modified the treatment.

To sort out the disagreement with the treating doctor, the injured worker can also approach the claims administrator with a request in writing detailing the areas of disagreement to prevent the loss of important rights.

Among reviews, IMR is the fastest and non-judicial way to resolve disputes. It came into being on July 1st, 2013, offering a resolution of all medical necessity treatment disputes for all dates of industrial injury.

The IMR is performed by an administrative director (AD) of the organization authorized to conduct IMR. For the IMR process, medical professionals are hired based on the high standards maintained.

IMR offers injured employees a review of the decision of the treating physician’s prescription of a particular course of treatment which may have been objected by the claims administrator. One common reason for rejecting a treatment plan is that the treatment is not medically warranted.

The dispute over medical necessity emanates from a physician’s preference for a certain course of treatment, which may be modified or rejected by the utilization review (UR).

The doctor will explain in the medical report the kind of work an affected worker can do while the recovery is in progress. It will also suggest the desired changes in work schedule and assignments.

The most competent people who are authorized to take a call on this matter are the doctor, employer, and the attorney hired by the worker. They would review the job description and discuss the changes needed on the job.

The resulting changes in work may see the employer giving a reduced amount of work to the injured worker or slash the time to complete certain tasks so the employee can still contribute and not feel like they are a burden on the team. This will also help the employee keep their spirits high.

A dispute can be managed by soliciting a medical evaluation process from a physician who can be the QME in case the injured employee is unable to hire an attorney.

The medical evaluation team will find out if the claim by the injured worker is payable and also look at the reasons for the delay and denial. Some of the grounds for inviting this QME scrutiny could be along the following lines:

• The injured worker is proclaimed permanently disabled and future treatment is recommended
• Discord remains on what the doctor says about a particular injury, any work or labor restrictions, or TD situation

Though in regards to this, a QME cannot make a final judgment on a basic request for medical treatment. That is why the denial of a doctor’s treatment request after the UR process must proceed to an IMR.

If a worker is represented by an attorney, he and the claims administrator can jointly choose a doctor who can treat the injured worker. The list of QMEs will be made available after the worker forwards a panel request form (QME 105) to the DWC Medical Unit.

A physician can also guide the injured worker on the right type of doctor who can treat him or her.

The worker and the insurance company will receive a list of three QMEs from the DWC Medical Unit within 20 working days of the request. Since the selection of QME lists is random it neither represents the employer nor the insurance firm.

From the list given by the DWC, the worker has to select a QME within 10 days and also inform the insurance company about his choice of a doctor with the date of appointment. If the selection of the doctor is not done by the worker within 10 days, then the insurance company will make its own choice and formalize the appointment.

Regarding the qualifications of QMEs, they have to be certified by DWC Medical Unit in various specialties. The QME must be a licensed physician eligible to practice in California. The QME fraternity includes medical doctors, chiropractors, psychologists, dentists, doctors of osteopathy, podiatrists or acupuncturists, and optometrists,

When an attorney and claims administrator jointly selects a doctor they can skip the QME selection process. Such a doctor jointly chosen by the legal professional and the claims administrator is called a medical evaluator (AME). But if they disagree on a consensus choice selecting a QME from the panel will be the next option.

The injured worker and claims administrator may disagree on what the doctor says regarding medical issues. In such a situation, a new doctor must address those disagreements that manifest themselves in the following areas.

• Cause of injury
• Whether the injury was really caused by work
• Need for future treatment
• Need for staying at home from work
• To proclaim the worker as permanently disabled or not

The best part is that by having the services of a QME (or AME), the scope of obtaining a concrete report becomes more realistic that will clearly define the benefits that the injured worker needs and should be entitled to.

An injured employee gets only a limited amount of time in deciding whether he agrees with the QME’s report or he must seek more information. To judge its accuracy, read the report quickly. If it is vague consult a legal counselor or any other options that are on the table.

If an attorney cannot be hired and the worker still believes there are factual errors in the QME’s report needing correction, he must ask for correction by issuing or asking for a request within 30 days of receiving the report.

Such a request for factual correction must also be endorsed by the claims administrator. 

Once the request for factual correction is received the QME must file a supplementary report with the DEU or Disability Evaluation Unit whether the factual correction is warranted and such corrections alter the opinions of the QME in the comprehensive medical report.

If the worker is active in a trade union, he can also consult an ombudsperson or mediator who has the mandate to intervene under the collective bargaining agreement.

In the following video, injured employees who returned to work, provide an understanding of the impact of the workers’ compensation system.

I’m Ed Smith, a Sacramento Workers’ Compensation Lawyer. When a person is hurt on the job during the scope of their duties, a workers’ compensation claim can make the difference to prevent an accident from becoming a catastrophe. If you or someone you love needs help, please call me right away at (916) 921-6400 or (800) 404-5400 for confidential, free and friendly advice. You can also reach me online via my website, AutoAccident.com.

Since 1982 I have worked to serve the Sacramento community, helping injured people and their families recover from accidents. 

Proud members of the Million Dollar Advocates Forum and the National Association of Distinguished Counsel.

See our past verdicts and settlements and our reviews on Avvo, Yelp, Google.

:br rey [cs 1532] 

Photo by Chang Duong on Unsplash

Editor’s Note: This page has been updated for accuracy and relevancy [cha 11.22.19]