Denied Treatment
Workers Compensation provides three main benefits to an injured worker. The most important benefit for an injured worker is medical treatment; however, this particular benefit is typically the most difficult to navigate.
I commonly hear injured workers say they wish they had never filed a claim for workers compensation benefits and that they should have just treated for the injury under private insurance. These injured workers correctly observe that they would have been back at work by now, but due to the treatment delays and denials they are worse off than right after the injury.
Many injured workers think that the silver bullet to these treatment denials is hiring an attorney- and while this is in part true, their odds of fighting back the constant treatment and medication denials are only improved by the quality of the attorney they hire.
There are some other things any injured worker can do, in addition to finding a good attorney to represent them.
Avoid misunderstandings, and know the process:
Every insurance carrier is entitled to review every treatment request by a physician, before authorizing the treatment, under a process called Utilization Review. If a doctor or pharmacy provides services that are not authorized they may not ever be paid for the services, so many doctors and pharmacies refuse to provide services without authorization from the insurance company.
The review process is 5 business days, but in no event more than 14 calendar days, from the date they receive a request for authorization from a physician.
This means that even if your doctor gives you a prescription or calls a prescription into your pharmacy the date of your appointment, the insurance company has up to 5 business days from the date the doctor submits a request to the insurance company for the medication or treatment. The date your doctor submits the request to the insurance company may be after the date of your appointment.
Avoid a misunderstanding, and save your time on the phone for where it will make the most impact. First call the doctors office, and find out what date the request was sent to the insurance company. Ask for a copy of the request if you do not have one. Second, if the request was submitted more than 5 business days ago, contact the insurance company and ask if there was authorization of the treatment. Ask for any documentation confirming their treatment determination. Third (or second if the claims adjuster does not answer or return your call) contact the pharmacy or service provider about your medication or appointment. If they say the insurance company did not authorize the treatment, ask them for some documentation to support their statement.
This will allow you to narrow down who is at fault; your doctor’s office, the insurance company, or the service provider / pharmacy.
This will also help your attorney, if you are represented, narrow down the issue and seek an order against the appropriate party if a judge needs to order the treatment to be provided.
Ensure you have a doctor who understands the Utilization Review Process
Even the most gifted doctor cannot do much for an injured worker if they do not know how to navigate the process of requesting treatment in a way that will result in that treatment being authorized. Many times treatment denials have little to do with whether or not an inured worker needs the treatment, and much to do with how the treatment is requested. If you have a doctor, or doctor’s office, that passes the buck and can’t seem to get treatment authorized, this may mean you are not treating with a doctor who understands the utilization review process. No matter how good they are at healing injuries, without authorization from the insurance company she/he will not be able to perform any of the treatment she/he has planned for you.
How do you find the right doctor? What if the insurance company is difficult?
This is one area where you will need to speak with an attorney, but not just any attorney will be able to assist. Find an attorney who works specifically in the field of workers compensation, and who practices in your area. You will not be able to find the right doctor by searching on the internet.
Be your own advocate
DO NOT WAIT FOR THE INSURANCE COMPANY TO SCHEDULE YOUR DOCTOR APPOINTMENTS OR TREATMENT.
Unfortunately, nobody will be doing much for you through the workers compensation claim process. Great doctors, experienced in handling workers compensation cases, can do a lot. An experienced workers compensation attorney, in your area, can get much done if legal issues arise. However, before you find the right doctor and attorney, if you sit at home waiting for the insurance company to call and tell you where to go, when, and what will happen, you will be waiting for a long time for a call that will never come.
Make appointments, attend appointments, call your providers, and this is no time to avoid being the “squeaky wheel”. Claims adjusters have dozens, and in some cases hundreds, of other claims and will prioritize their attention to the claimants who are proactive. The insurance company will not just continue your disability payments if you “lay low”, they will terminate them and claim that since you are not seeking treatment aggressively enough then you must not be injured.
Most professions have a culture where “complaining” or “going out on comp” is treated like a badge of shame. Ask yourself, who is the person who will need to cope with lifelong disabilities if prompt and adequate medical treatment is not provided? Your employer? Your work partners? Be proactive, because keeping quiet or not complaining will not get you back to your job sooner in the long term.
Written by Patrick C. Gorman, Esq. If you have any questions, call Gorman Law at 530-262-2168, or email: newclient@gormancomplaw.com
