The request for medical treatment on a workers’ compensation claim always begins with the doctor’s office. Medical treatment can be requested by an injured workers’ treating doctor or any of the referral specialists that they are treating with for their injury. It is extremely important to make sure that the doctor’s office who is requesting medical treatment understands the Utilization Review process. For a workers’ compensation claim, the request for medical treatment is reviewed by the Utilization Review department. Sometimes, Utilization Review (UR) is performed by a department within the insurance carrier’s company. Often times, UR is performed by a completely separate company.
When an injured workers’ doctor is requesting medical treatment, the request should be submitted to the Utilization Review department for approval. Once the request is received, the UR department has three business days to issue a decision. If your doctor’s office is telling you that they are going to request a certain type of medical treatment, and you do not hear back from them for several weeks – there is a problem. It does not take several weeks to get an answer back from UR for medical treatment. If there is a delay between the time the doctor’s office is telling you that they are requesting treatment and when you are hearing back from the doctor’s office, then there is an issue. We have had cases where the doctor’s office wants to request medical treatment and they are sending the request for approval to the wrong fax number or are sending it to the wrong person/department. If this is happening on your claim, it could explain part of the reason for the delay in medical treatment. This is why is it so important to make sure you are with a doctor who understands how a workers’ compensation claim operates. If you are with a doctor’s office that is unfamiliar with workers’ compensation or how the workers’ compensation process operates, this can create delays in your medical treatment.
Let’s say that your doctor understands the UR process and the requests for medical treatment are being filed timely. This, unfortunately, does not guarantee that medical treatment will be approved. When a request for medical treatment is denied, there can be several reasons for the denial. In order to decide how to appeal or challenge the denial, you must first figure out whether the denial is based on a medical reason or a legal reason. On one hand, medical treatment can be denied by the UR department because the information submitted did not meet the requirements to establish that the treatment was reasonable and necessary. In some cases, the doctor’s office may simply need to appeal the denial and provide the additional medical records and/or information requested. In other instances, the medical treatment might be denied because the requesting doctor was not available for a peer to peer.
Often times, the UR department may want to speak with the requesting doctor and this is commonly referred to as a peer to peer. However, what we see happen is that the UR department will call the requesting doctor’s office and the doctor is not available. As we previously discussed, the UR department has three business days to issue their decision, so if they need to speak with your doctor and the doctor is not available, then a decision will need to be made without the benefit of speaking with your doctor. Again, it is important to make sure that your doctor understands the UR process and is available to provide additional information to them, if requested.
The other reason that medical treatment can be denied by UR is if there is a legal reason – specifically, if there is an extent of injury dispute on your claim. If there is an extent of injury dispute on your claim, then that means that the insurance carrier is denying either a body part and/or a specific diagnosis as part of your compensable injury. If your doctor’s requests for medical treatment are being denied by the UR department or if your doctor is not getting paid for the services that are approved through UR, these can all be signs that there is an extent of injury dispute on your claim.
For example, let’s say the insurance carrier is accepting a lumbar sprain/strain as part of your injury, but your doctor says you have a herniated disc in your low back and you need an injection. When the doctor submits the request for an injection, the request will likely be denied because an injection would not be reasonable and necessary for a sprain/strain. For an extent of injury dispute, a Hearing through the Division of Workers’ Compensation would need to be requested to resolve the dispute. Without taking these steps, your medical treatment will probably continue to be either delayed or denied.
If you are currently having problems with getting your medical treatment approved, please contact our Firm and one of our attorneys would be happy to speak with you about your case.