If you disagree with the treatment in your workers’ compensation medical report, you can challenge it. In California, the process depends on your circumstances, such as whether you are part of a Medical Provider Network (MPN) or a Health Care Organization (HCO). Understanding these steps can help you take action to ensure you receive the appropriate care.
Understanding the disagreement
Before acting, clearly identify why you disagree with the report. Common reasons for disagreement include:
- Injury cause
- Required treatment
- Work restrictions during recovery
If your disagreement concerns the necessary treatment, your options depend on whether you receive care within an MPN, an HCO, or neither.
Steps for challenging treatment opinions
If Treated within an MPN
You can switch doctors within the MPN if you disagree with your treatment. Your employer or insurer should provide instructions on how to do this. If you still disagree, you can get second and third opinions from other MPN doctors. You must make these appointments within 60 days of receiving the list of available doctors.
If you still disagree after the third opinion, request an independent medical review from the Division of Workers’ Compensation (DWC). If the review supports your view, you may receive treatment from a doctor outside the MPN.
If treated within an HCO
You can request a change of doctors, and the HCO must offer a choice within five days. If disagreements continue, the HCO must use an expedited grievance procedure to resolve the dispute within 30 days.
If not in an MPN or HCO
Consider switching to another doctor. If this isn’t an option or doesn’t resolve the issue, send a letter to the claim’s administrator stating your disagreement.
If you don’t have an attorney, you must send this letter within 30 days of receiving the report. With an attorney, they must send it within 20 days. Obtain a medical evaluation from another doctor.
If you don’t have an attorney, the claim’s administrator will provide a form to select a Qualified Medical Evaluator (QME). Complete this process within specified deadlines. If you have an attorney, they may negotiate for an Agreed Medical Evaluator (AME) or follow a similar QME process.
Navigating workers’ comp disputes can be complex. Legal advice can help you understand your rights and ensure you follow the correct procedures. An experienced workers comp attorney can assist with paperwork, communicate with the claim’s administrator, and represent your interests effectively.
If you disagree with your medical report’s treatment recommendations, you have several options to challenge it. Whether you are in an MPN, HCO, or neither, understanding the steps can help you advocate for the care you need.