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Adjuster changed PTP from Neuro to Ortho for Brain Injury.
#1
Hi, how would you fight a insurance company changing the doctor you've had for years to someone who is not qualified to treat you? They changed my friend who has a nasty brain injury from a Neuro-Psyche specialist to a Ortho-Plastic surgeon. It make's no sense to me why their adjuster would change their PTP to a Ortho unless he's a hired gun. He's not qualified for brain injuries, what would you do because my friend was getting help with their neuropyche doctor. This forum is one of the last places anyone can get help, thank you!
 
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#2
(10-29-2018, 01:57 PM)Billy Miller Wrote: Hi, how would you fight a insurance company changing the doctor you've had for years to someone who is not qualified to treat you? They changed my friend who has a nasty brain injury from a Neuro-Psyche specialist to a Ortho-Plastic surgeon. It make's no sense to me why their adjuster would change their PTP to a Ortho unless he's a hired gun. He's not qualified for brain injuries, what would you do because my friend was getting help with their neuro-psychiatrist doctor. This forum is one of the last places anyone can get help, thank you!



The Insurance Carrier cancelled my friends appointment last week and sent a letter getting received on Saturday stating they are choosing which PTP the IW is to see. Are they allowed to cancel your PTP with no notice and demand you see their Hired Gun doctor with no relevant experience with TBI? My friend is messed up, almost been reduced to a child after getting hit by a student. The only way I see this is the Insurance company feels the PTP previously was too IW friendly, they want someone who is Insurance Company friendly. No notice, cancelled the appointment last week and set up a new PTP after being seen by the previous PTP for two years.
 
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#3
Difficult to answer without knowing what state this is in as the laws are state specific.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#4
It looks like from your other posts this is a California case? If so your friend can chose any doctor in his employers medical treatment network. Does he have access to this? If his doctor is no longer in the medical provider network they can give notice to the injured worker they can no longer see the doctor. However there is a rule that if the treating doctor agrees and if the condition qualifies he can request to treat with the doctor up to another year.

Did you see the notice given to your friend? I am checking because he may have received notice of a qualified medical evaluation. What did the letter say, a change in primary treating physician or a notice of appointment with an AME or QME? Was the letter from his attorney or adjuster?

It is difficult to answer questions like this due to minimal facts. As I wrote above he should be given access to his insurance carriers medical provider network and he can chose his own doctor from there and also check to see if his current doctor is on it. The doctors office may have additional information and he can call them and ask about the letter and if they will continue to see him.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#5
(10-29-2018, 05:48 PM)California_Help Wrote: It looks like from your other posts this is a California case? If so your friend can chose any doctor in his employers medical treatment network. Does he have access to this? If his doctor is no longer in the medical provider network they can give notice to the injured worker they can no longer see the doctor. However there is a rule that if the treating doctor agrees and if the condition qualifies he can request to treat with the doctor up to another year.

Did you see the notice given to your friend? I am checking because he may have received notice of a qualified medical evaluation. What did the letter say, a change in primary treating physician or a notice of appointment with an AME or QME? Was the letter from his attorney or adjuster?

It is difficult to answer questions like this due to minimal facts. As I wrote above he should be given access to his insurance carriers medical provider network and he can chose his own doctor from there and also check to see if his current doctor is on it. The doctors office may have additional information and he can call them and ask about the letter and if they will continue to see him.


Dear CAHelp, I meet someone who got badly injured while working as a high school teacher. The insurance company started out playing nice until a Neuro-Psych PTP pulled the IW's license and now the insurance carrier is fighting that. Carrier is angry because they don't want to pay for a driver. In our areaa there are no specialists, only a hired-gun orthopedic doctor who has no neurology, psychology or psychiatrist skills.


The nearest brain-injury PTPs are in the Big Cities(San Diego, Los Angeles, San Jose). So without any notice the adjuster cancelled the IW's appointment, no notice was given. On Saturday a certified pack arrived telling the IW they accept blame for the head and spinal injury, they want the IW to go to the orthopedic-Botox specialist. I did not know Orthos can treat severe brain injuries, injuries that change your personalities and mental function.


I thought the insurance company was ok as long as the PTP was part of the MPN. The problem is this insurance company does not have a big network even in the large cities. The adjuster said they will not pay for a driver, they want the injured worker to drive even after the PTP and QME neurologist said driving was not safe.
 
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#6
(10-29-2018, 09:12 PM)Billy Miller Wrote:
(10-29-2018, 05:48 PM)California_Help Wrote: It looks like from your other posts this is a California case? If so your friend can chose any doctor in his employers medical treatment network. Does he have access to this? If his doctor is no longer in the medical provider network they can give notice to the injured worker they can no longer see the doctor. However there is a rule that if the treating doctor agrees and if the condition qualifies he can request to treat with the doctor up to another year.

Did you see the notice given to your friend? I am checking because he may have received notice of a qualified medical evaluation. What did the letter say, a change in primary treating physician or a notice of appointment with an AME or QME? Was the letter from his attorney or adjuster?

It is difficult to answer questions like this due to minimal facts. As I wrote above he should be given access to his insurance carriers medical provider network and he can chose his own doctor from there and also check to see if his current doctor is on it. The doctors office may have additional information and he can call them and ask about the letter and if they will continue to see him.


Dear CAHelp, I meet someone who got badly injured while working as a high school teacher. The insurance company started out playing nice until a Neuro-Psych PTP pulled the IW's license and now the insurance carrier is fighting that. Carrier is angry because they don't want to pay for a driver. In our areaa there are no specialists, only a hired-gun orthopedic doctor who has no neurology, psychology or psychiatrist skills.


The nearest brain-injury PTPs are in the Big Cities(San Diego, Los Angeles, San Jose). So without any notice the adjuster cancelled the IW's appointment, no notice was given. On Saturday a certified pack arrived telling the IW they accept blame for the head and spinal injury, they want the IW to go to the orthopedic-Botox specialist. I did not know Orthos can treat severe brain injuries, injuries that change your personalities and mental function.


I thought the insurance company was ok as long as the PTP was part of the MPN. The problem is this insurance company does not have a big network even in the large cities. The adjuster said they will not pay for a driver, they want the injured worker to drive even after the PTP and QME neurologist said driving was not safe.

I will look to see treatment guidelines for transportation. It appears the injured worker needs to have his doctor request transportation.

I am looking for medical treatment guidelines for transportation for brain injury patients however this IMR doctor used an Aetna guideline that is pretty generic to overturn the UR denial. The injured workers condition is not a brain injury, but it looks generic. I will try to find guidelines for brain injury transportation.

https://www.dir.ca.gov/dwc/IMR/IMR-Decis...186127.pdf

There are rules about MPN's having to have certain number of specialty within a certain area. The issue may need to be litigated if the claims adjuster refuses and perhaps the injured workers attorney can request to treat outside of the MPN if they do not want to pay transportation so far away.

Are there any neurologists in this area within the MPN?

These can be complex issues for an injured worker to deal with. If he does not have an attorney I recommend he seeks help with an information and assistance officer.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#7
This should help with access questions.

https://www.dir.ca.gov/t8/9767_5.html

This is transfer of care info.

https://www.dir.ca.gov/t8/9767_9.html

If the doctor was removed from the MPN.

https://www.dir.ca.gov/t8/9767_10.html

MPN rules and links.

https://www.dir.ca.gov/t8/ch4_5sb1a3_5.html
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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