As an authorized treating provider (ATP), you should be able to make maximum medical improvement (MMI) decisions on your own in the vast majority of instances. Delays with these decisions, however, can adversely impact an injured worker’s recovery. If a case seems “stuck,” then a second opinion may help move a case forward by providing you with additional ideas related to diagnosis and treatment. Alternatively, a second-opinion physician may conclude that a patient has reached MMI. This last outcome can be helpful if a patient is frustrated, angry or otherwise reluctant to agree with your own sense that MMI has been reached (sometimes these conversations can be challenging, especially if you are also the patient’s regular primary care provider).
Some providers believe that if a case has stalled then they should request an independent medical evaluation (IME). IMEs, however, are usually requested by the insurance company or an injured worker’s attorney when there is a dispute regarding an MMI determination or impairment rating. IMEs also are expensive and can be difficult to schedule in a timely manner.
Instead of requesting an IME, you can — as the ATP — refer the injured worker to another physician for a second opinion. Ideally, the second-opinion physician will be knowledgeable in occupational medicine and will be Level II accredited with the Colorado Division of Workers’ Compensation. Also, the second-opinion physician should work in an unrelated clinic. A list of Level II accredited physicians can be found here.
It is helpful if you pose a specific set of questions for the second-opinion physician to answer. When referring the injured worker, you should make it clear that you expect the second-opinion physician to answer your questions by rendering an opinion, and that you do not expect the physician to assume care or co-manage the case.
If for some reason it is not feasible to send the patient for an in-person second opinion, you may consider the possibility of a telehealth visit or ask the physician to carry out a medical record review. Again, it is helpful to prepare a specific set of questions for the reviewer to answer.
In summary, second-opinion referrals (rather than IMEs) are valuable tools for ATPs to move forward with treatment, manage a claim and finalize MMI. If you have any questions, do not hesitate to contact your Pinnacol provider relations specialist.
Please note that this communication is not intended to direct care. You must rely on your independent, expert judgment when treating patients in the workers’ compensation system.
Strategies for Delayed Recovery
Colorado Regulatory Statutes - Medical impairment benefits CRS 8-42-107(8)