WCB Procedures

Conflict of medical/psychologist opinion

Procedure summary

Published On

Dec 13, 2022

Purpose

This procedure guides the decision maker through the steps necessary to identify and resolve a conflict of medical or psychological opinion and to make a decision about an issue within a claim.

Description

The decision maker reviews all information to determine whether there is a true conflict of medical or psychological opinion or there is only a difference of opinion.

When a true conflict of medical or psychological opinion exists, the decision maker weighs the evidence and works to resolve the conflict.

When the conflict of opinion cannot be resolved, the decision maker contacts the physician or psychologist to share or request any additional information and sends a letter to request and/or to confirm whether their opinion has changed.

After reviewing any new information, if a decision still cannot be made to resolve the conflict of opinion the decision maker refers the issue to the WCB internal consultant and/or arranges further investigation or testing if needed.

The decision maker communicates the decision and shares the rationale with the worker.

Key information

In this procedure, a medical opinion is provided by a physician. A psychological opinion is provided by a psychologist.

A true conflict of medical or psychological opinion happens when more than one medical or psychology professional, whose opinions carry equal weight, reach different and conflicting conclusions.

Equal weight opinions require the following:

Similar qualifications or expertise.
The same facts about the worker’s injuries.
Examines a worker within the same time frame.

Conflicting opinions may arise between two external physicians and/or psychologists. It may also occur between one or more external physician, psychologist, physiotherapist and/or one or more WCB internal consultant.

Differing opinions are not necessarily conflicting opinions. A difference of opinion may be attributed to the worker being examined at different times during their recovery, or the physician or psychologist not having all the same facts, resulting in opinions that are different but not in conflict.

Additional resources are available for this procedure in the internal Procedure Resource Library.

Detailed business procedure

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1. Review the information and determine if there is a true conflict of medical opinion Is all the relevant information on file? Confirm the physicians or psychologists have provided a full statement of facts and evidence, including reasons, to support their conclusions. If any of the above are missing, there is no conflict of opinion. When there is a conflict of opinion, consider the following to determine if the professional opinions carry equal weight: An examination generally carries more weight than a documentary review. A specialist's opinion generally carries more weight than a general practitioner's opinion. A specialist in family medicine is equivalent to a general practitioner. A treating psychologist or counsellor is equivalent to a general practitioner in psychological terms. A practitioner with a doctorate or a specific area of expertise generally carries more weight. Speak with the supervisor, the psychology assistant or the clinical consultant for assistance with determining which training and credentials carry the most weight and whether the reporting/opinions are conflicting and require a referral. When the professional opinions do not carry equal weight, there is no true conflict of opinion. Weigh the evidence and make a decision about the issue under review; go to step 5. When the professional opinions carry equal weight, but their opinions differ, there is a true conflict of medical opinion. If a conflict of medical/psychological opinion exists, determine whether more information is needed to resolve the issue.	Administrative tasks There are no administrative tasks for this step.
2. Confirm the physician and/or psychologist has all the relevant information and provide any that is missing Contact the physician or the psychologist to determine if they have all of the information needed to provide a professional opinion. If necessary, provide them with any missing information, such as: Date of accident (DOA) and a chronology of events and/or a clear description of the accepted mechanism of injury. What injuries and/or conditions are accepted and not accepted on the claim. Job duties, physical demands analysis, progressive injury questionnaire, return-to-work planning meeting, etc. Medical guidelines for progressive type injuries, such as repetitive strain injury claims. Medical or psychological consultant review (if available). Relevant medical reports, such as physiotherapy or psychological reporting, medical status exam and/or functional capacity exam reporting, etc. Call the treating physician or psychologist within one week of sending the letter to confirm whether their opinion has changed and/or if further information is being submitted.	Administrative tasks Remove any personal, third-party or confidential information prior to sending the documents. Contact the Access to Information team to review and redact sensitive information and send the information to the recipient. Send a Difference of Opinion (SP006G) letter and include the timeline for them to provide a medical or psychological opinion. Pay a telephone report fee, if appropriate.
3. Review the response and any new information to determine if the conflict of opinion still exists Determine whether the physician or psychologist has provided any new information and/or whether there is still a true conflict of medical or psychological opinion. Weigh the information and evidence: Has new evidence been provided? Can a decision be made for the issue under review? When there is no new information and/or no true conflict of opinion, use the current information to weigh the evidence. Go to step 5.	Administrative tasks There are no administrative tasks for this step.
4. Take the appropriate steps to resolve the true conflict of opinion If there is a true conflict of medical or psychological opinion, further investigation may be required. The conflict of opinion may be addressed and resolved by one or more of the following: Discuss the claim with a supervisor, clinical, medical or psychological consultant to determine the most appropriate actions. Provide additional information to the medical/psychological professional for consideration. Contact the parties involved to explain how/why information was weighed in making the decision. Refer the claim to the WCB internal consultant to call the treating or assessing physician or psychologist. Refer for an independent medical examination (IME). Refer for a psychological assessment. Consult with a psychological assistant for an opinion about which exam is appropriate. Discuss the claim with the medical status exam (MSE) physician and if appropriate, request they contact the community physician to discuss the differences and the steps required for resolution. Note: When there is a true conflict of opinion between WCB consultants, refer the claim to the consultant who reviewed it last and request a consensus opinion. Following additional investigation and/or results of assessment, review the evidence and determine if the conflict of opinion has been resolved. If the conflict has been resolved, go to step 5. If a consensus cannot be reached, refer the issue to an appropriate medical services manager or the psychological services team lead.	Administrative tasks Follow the Internal consultant referral procedure and/or the Medical testing, referrals and program support procedure. Call or email the medical services manager or the psychological services team lead to refer a file when a resolution cannot be reached.
5. Communicate the decision Verbally communicate the decision and next steps, if any, to the worker and follow up by sending a custom letter. Clearly express the rationale used to reach the decision (citing policy, medical information on the file and any important background information) during the conversation as well as within the letter.	Administrative tasks Send a Claimant Custom (CL000A) letter to all parties involved explaining how the information was weighed and how the decision was made.

Supporting references

Policies

Procedures

Workers’ Compensation Act

Applicable sections

34 (5)
38 (1)
38 (3)

General Regulation

Applicable sections

Related Legislation

Applicable sections

Medical Panels Regulation

Compatibility Warning

WCB Procedures

Conflict of medical/psychologist opinion

Procedure summary

Detailed business procedure

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Supporting references

Policies

Procedures

Related links

Workers’ Compensation Act

General Regulation

Related Legislation