When an employee gets injured on the job, getting the right medical care at the right time is crucial for recovery. Most of the time, the initial treating physician provides effective care that gets your employee back on their feet.
But what happens when treatment isn’t progressing, or complications arise that leave everyone uncertain about the best path forward? That’s where a second medical opinion can make a difference.
On this episode of the WorkSafe Podcast, we explored these scenarios with Shannon Fox, Claims Operations Manager at MEM. With decades of experience managing complex claims, Shannon knows exactly when second opinions become valuable – and how to navigate the process.
When second opinions make sense in workers compensation
Second opinions aren’t needed for every claim, but certain red flags signal it might be time to seek another medical perspective.
Red flag #1: Signs that treatment isn’t progressing
“The most dynamic situations arise when there is a disconnect between the injured worker, their reported symptoms, complaints and clinical findings,” said Fox. This might look like:
- An injured worker isn’t improving as expected despite following the treatment plan
- Treatment recommendations seem excessive or inconsistent with the original diagnosis
➡️ Here’s an example: An employee is treated for a back injury for six months with no improvement. Despite physical therapy and medication, they can’t return to work. A second opinion might reveal whether the original diagnosis missed something or if the treatment approach needs adjustment.
Red flag #2: Underlying medical conditions that complicate recovery
Pre-existing health conditions can impact how workplace injuries heal. Fox explained, “an individual who had something fall on their foot, but they have the underlying medical issue of diabetes. That diagnosis can delay medical treatment. It can change the answer to ‘What are we treating for?'”
Sometimes, underlying conditions aren’t obvious. If a female employee develops carpal tunnel syndrome, a second opinion might determine whether thyroid issues are contributing factors.
Red flag #3: Extended lost time and stagnant treatment
When conservative treatment extends beyond what’s typical without progress, consider additional medical input. Fox noted that sometimes treatment for one area evolves to include related body parts, like a lumbar spine injury affecting the cervical spine.
💡 Pro tip: Don’t wait until treatment has been ineffective for months. Early intervention with a second opinion can prevent prolonged disability and get your employee the specialized care they need sooner.
Who can request a second opinion
Who has the authority to request and authorize second opinions? The answer to this complex but important question varies by state.
State variations in authority to direct medical care
“In Missouri, the employer has the exclusive right to direct medical treatment,” Fox explained. “That indicates that an injured worker cannot seek a second opinion on their own, and expect the employer or insurer to pay for it. We have to authorize that.”
However, an employer’s right to direct medical care isn’t universal. In Illinois, injured workers can generally choose their own doctors – typically up to two physicians, though employers with Preferred Provider Programs can limit these choices. Kansas follows a model similar to Missouri, where the employer or insurance carrier selects the treating physician.
Authorization requirements across different states
In many employer-directed states, requests for covered second opinions must come through proper channels. Insurance carriers evaluate these requests based on medical necessity. However, every state is different: In Kansas, second opinions are covered up to a certain dollar amount without prior authorization.
What happens when injured workers seek opinions independently
If an injured worker obtains a second opinion without authorization, they may be responsible for the cost. But this doesn’t mean the information is ignored. “In instances like that,” Fox said, “we obtain the medical report so we can clarify if it will persuade the decisions that we’re making on the file.”
For injured workers, the best approach is to stay within the approved provider network and maintain open communication with their employer and carrier to ensure coverage.
When insurers initiate second opinions
Insurance carriers can request second opinions when they believe it’s medically necessary. Common reasons include:
- Confirming a diagnosis when treatment isn’t progressing
- Evaluating treatment effectiveness
- Addressing delayed recovery or complications
- Clarifying permanent work restrictions
💡 Pro tip: Choosing a work comp carrier with in-house claims management, including nurse case managers, adds value for employers and injured workers. These professionals identify when second opinions are needed, coordinate care between providers, and keep treatment on track – often catching issues before they become major complications.
Second opinions vs. independent medical examinations
Second opinions and independent medical examinations (IMEs) serve different purposes in work comp claims.
IMEs clarify compensability – whether an injury truly arose from a workplace incident. They come into play during disputes about medical issues or disability ratings. “It’s not necessarily for ongoing care, but rather to clarify how a claim should move when there’s litigation or a settlement involved,” Fox explained.
Second opinions focus on ongoing medical treatment. They address questions about current treatment and determine the best plan of care for optimal outcomes.
How MEM handles the second opinion process
When a second opinion is warranted, careful coordination ensures a smooth process.
Behind-the-scenes coordination
“We have about 40 claims adjusters at different severity levels who handle files,” Fox noted. The process varies based on adjuster experience, claim complexity, and state regulations.
We determine whether a second opinion is the best course within applicable state laws through discussions between adjusters and nurse case managers about which physician would be most appropriate. MEM draws on decades of experience working with specialists to make these selections.
📍 Need help navigating the complexities of work comp claims? Download our claims management kit for practical resources and guidance.
What employers and injured workers can expect
Once a second opinion is deemed appropriate, MEM handles the logistics. This includes scheduling, authorizing treatment, and managing communication. “We take care of all of that information and make sure the injured worker knows where they’re going and the employer understands the purpose,” Fox said.
Geography can be a factor, especially in rural areas. While we minimize travel, accessing the right specialist sometimes requires distance. We balance convenience with getting the most appropriate evaluation.
After the exam, we quickly assess recommendations. This might involve switching care to the second opinion physician or incorporating their recommendations. Our expert medical management team ensures decisions consider both medical best practices and practical considerations.
Real-world example: When a second opinion changed everything
Second opinions can be very valuable. Fox shared a compelling example from her experience managing claims.
Fox shared a compelling example: “I can recall a claim involving a back injury where the treating physician kept the injured worker on very limited duty for over six months with no improvement.” The injured worker remained unable to work.
MEM arranged for a second opinion with a spine specialist. “He evaluated the case and discovered that the diagnosis involved a disc issue, which was overlooked by the prior physician,” Fox explained.
This changed everything. Instead of continuing ineffective care, the injured worker got targeted treatment addressing the actual disc issue.
☑️ The bottom line: The second opinion identified the real problem and connected the injured worker with the right specialist, leading to meaningful improvement after months of frustration.
When second opinions aren’t recommended
While second opinions can be valuable, they’re not appropriate in every situation. Understanding when to stay the course is just as important as knowing when to seek additional input.
Signs that current treatment should continue
If the treating provider follows evidence-based guidelines and the injured worker is progressing well, a second opinion might only add unnecessary cost and delay. “In those cases, we may stay the course to avoid disrupting care,” Fox said.
Timing matters. If a provider is early in their treatment plan without adequate time to evaluate results, jumping in too quickly can create confusion.
Balancing medical necessity with claim integrity
Carriers aren’t obligated to approve every second opinion request. “We always consider the request, but we have to balance it with medical necessity and the integrity of the claim,” Fox explained.
Carriers consider factors such as:
- Medical justification: Clinical evidence supporting additional evaluation
- Treatment effectiveness: Whether current care follows evidence-based guidelines
- Cost-benefit analysis: Potential for improved outcomes versus expenses
- Timing considerations: Whether adequate time has passed to evaluate treatment
Supporting your injured worker through the process
When second opinions come into play, employers play a crucial role in supporting the injured worker while working collaboratively with their claims team.
Staying connected with your claims team
“My best advice is to stay connected with the claims team; the adjuster on your file,” Fox recommended. “If there’s a nurse assigned to your file, stay connected, because you’re never navigating this process alone.”
Your adjuster can walk you through the reasoning behind recommending a second opinion, help with timing decisions, and manage logistics.
Want to understand how different claim types impact your business? Explore our insights on frequency vs. severity in claims management.
Framing second opinions positively
One concern employers have is that requesting a second opinion might damage trust. “A second opinion, when handled thoughtfully, is not about questioning the employee,” Fox emphasized. “It’s about making sure we’re doing everything we can to support their recovery.”
Strategies for positive communication:
- Focus on clarity: Second opinions are tools for understanding the best path forward.
- Show support: This is comprehensive care, not questioning their injury.
- Maintain transparency: Explain the process so everyone knows what to expect.
- Be a partner: Everyone is working toward the same goal: recovery.
The bottom line on second opinions
Second opinions help ensure injured workers receive appropriate care. Whether identifying a misdiagnosed condition, addressing complications from underlying health issues, or clarifying the best treatment approach when progress stalls, second opinions can redirect claims toward better outcomes.
Seeking a second opinion represents good stewardship, not doubt. It demonstrates commitment to thoughtful care that prioritizes recovery while managing claims responsibly. By staying in close communication with your claims team and asking the right questions early, you can navigate the process effectively.
At MEM, personalized claims care is one of our top priorities. Learn more about our comprehensive approach to handling claims.