Probably the most common reason people call me is medical treatment denials. These denials come in several forms:
- An actual denial – “We are denying payment for your surgery.”
- A partial denial – “We will approve your medical treatment but you have to have it with a different medical provider.”
- A medical delay – “We do not know yet whether we will approve your surgery or not. We need to get a second opinion before we make a decision.”
- No answer at all – The doctors office has called, faxed, and emailed but cannot get a response from the insurance company
The insurance company should pay for the medical treatment for your injury. That rule is fundamental to Georgia workers’ compensation law.
Why do insurance companies deny medical treatment?
Insurance companies make most of their decisions to make money. After all, they are for profit businesses.
When they deny medical treatment, they are probably doing it to try to save money. Paying for your medical treatment costs the insurance company money. They make more money if they do not have to pay for some of your medical treatment.
What can you do about medical treatment denials
To beat medical treatment denials, you first need to know if the insurance company has a valid reason for denying treatment. To do that, you need to understand the law.
Georgia’s workers’ compensation law on medical treatment has some basic rules:
- Your authorized treating physician (ATP) directs your medical treatment.
- The insurance company should pay for the medical treatment ordered by the ATP.
- The insurance company should also pay for medical testing ordered by the ATP.
- Your authorized treating physician may refer you to other doctors for specialized care. The insurance company should also pay for those referrals.
The insurance company does not have to pay for “unauthorized treatment”. “Unauthorized treatment” could be treatment provided by a doctor other than your authorized treatment physician or a referred physician. There are some exceptions where the insurance company can have to pay for this treatment e.g. emergency treatment, but the exceptions are pretty limited.
What if the insurance company does not have a valid reason for denying medical treatment?
If the treatment is ordered by the authorized treating physician, then the insurance company should probably pay for it. If they are not, then there are some things that can be done to get the treatment.
Get the insurance adjuster on the phone
Getting the adjuster or case manager on the phone can be hard. Many times you may just get voicemail. However, it can solve some medical treatment denials.
Sometimes, the adjuster may need the right information from the doctor’s office before approving the treatment. You can sometimes help get this information to them. If you have an attorney, your attorney should help do this.
What if the adjuster approves the treatment but says you have to get it done with a different doctor in their network? This is almost always not true.
Georgia workers’ compensation law usually does not have “networks”. This means that your authorized treating physician chooses which doctor you see. The insurance company does not get to pick. There are exceptions to that if your employer uses a WC/MCO instead of a traditional panel of physicians.
Send a Form WC-205 to request approval
The Georgia State Board of Workers’ Compensation created a form to make adjusters respond to request for approval. This form attempts to solve the problem of the adjuster not responding at all.
The doctor’s office can send this form to the insurance company to request approval for treatment. The insurance company has a deadline of 5 business days to respond. If there is no response, the treatment should be automatically approved.
A Form WC-205 can help beat a medical treatment denial. Sending one should get the treatment approved or get an answer about why it is being denied.
Send a Form WC-PMT to schedule a phone call with a workers compensation Administrative Law Judge
In July 2017, the Georgia State Board of Workers’ Compensation created a new way to get medical treatment approved. You or your attorney can use a Form WC-PMT to request a phone conference with a workers compensation judge. This article discusses more about how to file a Form WC-PMT and what happens after you file it.
Request a hearing with a workers compensation Administrative Law Judge
You can always choose to take the insurance company to court. This provides you the opportunity to explain to get a decision from a judge about whether the insurance company must pay for the medical treatment.
Judges have the power to order the insurance company to pay for medical treatment. Getting the medical treatment you need will help you get better.
If the insurance company delays or denies your medical treatment, you should probably talk to a workers compensation attorney
I mentioned earlier that people call me more about medical treatment denials than anything else. There is good reason for that. They want to get the medical treatment they need to stop their pain and move on with their lives.
Beating medical treatment denials is complicated. Sometimes, I will try to talk to the insurance adjuster to get the treatment approved. Other times, requesting a hearing is the best choice.
The best choice depends on the specific facts of your case. Every case is different. Good workers’ compensation attorneys can find out about your specific situation and give advice on the best way to beat a medical treatment denial.