Expert Medical Advisor – Resolution Of Medical Disputes
It is often the case that disputes develop around the medical necessity of certain types of medical procedures. For example, a doctor recommends a specific procedure, and the carrier, like the claimant, would have a right to an independent medical examination. If the carrier’s independent medical examination concluded that a particular surgical procedure was not medically necessary, it is likely the carrier would deny authorization for the procedure, even though it was recommended by the authorized treating physician (that the insurance company initially selected). Alternatively, the authorized treating physician might feel the surgical procedure is not medically necessary or related to the injuries sustained in the accident. If the claimant’s independent medical examiner feels a specific procedure is medically necessary and related to the accident, then clearly a dispute would exist with regard to the carrier’s obligation to provide authorization for the procedure.
The Workers’ Compensation Act contains a provision to address these types of conflicts in medical evidence: the expert medical adviser provision.
Physicians are utilized by the Division and Judges of Compensation Claims as Expert Medical Advisors (EMAs) to render expert medical opinions, peer review and expert testimony to resolve disputes related to reimbursement, differing opinions of health care providers, and health care and physician services rendered in accordance with subsection 440.13(9), F.S. and Rule 69L-30.007, F.A.C.
The provision specifically addresses that in cases where there is a clear dispute regarding the need for ongoing medical treatment, or entitlement to certain categories of disability benefits, the court on its own, or through the motion of one party or the other, MAY be obligated to appoint an expert medical adviser. This is a physician typically selected by the Judge of Compensation Claims or, under certain circumstances, by the attorney for each party. The expert medical adviser is similar to an independent medical examiner, but the exception is that the opinion of an expert medical adviser is presumed to be correct and can be overcome only in exceptional circumstances.
In May of 2023, the EMA provision changed from mandatory to selective – on the part of the Judge of Compensation Claims. Therefore, a Judge MAY appoint an expert medical advisor to break a medical dispute.
Do You Have More Questions About Expert Medical Advisors?
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