The workers’ compensation doctor says that I should have surgery, but my employer utilized some type of managed care organization, and their doctor, who has never seen me, wrote a letter and recommended that the workers’ compensation carrier not pay for the surgery. I need to get this surgery. What am I supposed to do now?

If the workers’ compensation doctor is the treating physician, and is not a second opinion physician that you were sent to by workers’ compensation, and you are covered by a contract with that Managed Care Organization, you may be required to exhaust all dispute resolution procedures of that organization before moving forward; however, you are allowed under the rules to obtain, one time, another doctor’s opinion who is within that managed care organization’s panel. You may do that without any approval from the employer or insurer. If that second opinion doctor recommends you have the surgery, the insurer must authorize the surgery.

After you have exhausted the dispute resolution procedure and/or seen another doctor who is on the managed care organization’s panel, and surgery is still not approved, you may seek further redress from the Commission.

Note that none of this applies if you were required by the insurer to submit to an Independent Medical Examination, (IME) in other words, a second opinion by the workers’ compensation carrier. If that second opinion doctor says that you need the surgery, then the insurer must authorize that surgery. In other words, if the workers’ compensation insurance company requires you to get a second opinion, and the second opinion doctor says you need the surgery, they are stuck with that opinion, and there is nothing they can do about it. Under the rules, they must pay for the surgery, assuming it is related to your compensation claim.