When it comes to workers’ compensation, medical disputes can feel like an endless game of “Doctor, Doctor!” Fortunately, California Code of Regulations §9767.7 provides a clear roadmap for when an employee is not quite feeling what the primary treating physician is dishing out. At Yrulegui & Roberts, we love helping employers, insurers, and claims adjusters navigate this process with ease and a dash of humor.
The Employee’s Right to a Second (and Third!) Opinion
If an employee disputes their primary treating physician’s diagnosis or treatment plan within the Medical Provider Network (MPN), they have the right to seek a second opinion. If that second opinion does not hit the mark, they can go for a third! Do not worry—this process is still confined to the MPN, so there is no free-for-all doctor shopping.
While this dance of second and third opinions plays out, the employee can either keep seeing their original doctor or pick another physician within the MPN.
The Employee’s “To-Do” List
To kick off the second (or third) opinion process, the employee has a few responsibilities:
- Inform the employer or insurer (either verbally or in writing) that they are not vibing with their current diagnosis or treatment.
- Select a second opinion physician from the MPN provider list.
- Schedule an appointment within 60 days and let the employer or insurer know when it is happening.
- If they are still unhappy after the second opinion, the employee can follow the same steps for a third opinion.
The Employer’s and Insurer’s “To-Do” List
On the flip side, employers and insurers have some homework, too:
- Provide the employee with a list of available MPN physicians or specialists with expertise in treating the employee’s specific injury.
- Make sure the employee knows they can request their medical records to be sent to the second or third opinion physician.
- Notify the second or third opinion physician in writing about the nature of the dispute (and send a copy to the employee—no secrets here!).
If the chosen second or third opinion physician cannot handle the particular injury, the employer or insurer must provide a new list of MPN physicians.
After the Third Opinion—Now What?
If the employee still is not satisfied after the third opinion (yes, really), they can request an Independent Medical Review (IMR) from the California Division of Workers’ Compensation. This final step ensures the employee gets appropriate care without the employer or insurer being stuck footing the bill for unnecessary treatments.
What This Means for Employers and Insurers
For employers and insurers, California Code §9767.7 offers a structured way to handle disputes. It ensures that employees continue to receive care while keeping the process within the MPN. Compliance is key, so be sure to respond to employee requests in a timely manner, keep those medical records handy, and communicate clearly with all parties involved.
At Yrulegui & Roberts, we specialize in helping employers and insurers navigate the twists and turns of workers’ compensation claims, ensuring that you are always a step ahead in managing disputes and protecting your interests.
