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Beating Insurance Company Medical Treatment Denials

Probably the most common reason people call me about their workers compensation case is medical treatment denials by the insurance company.  These treatment 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 with authorized doctors.  That rule is fundamental to Georgia workers’ compensation law.  Unfortunately, insurance companies often refuse to follow the rules requiring them to pay for medical treatment.

Why do insurance companies deny medical treatment?

Insurance companies make most of their decisions to make money. After all, they are for profit businesses.  The goal of the business is to make a profit.

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.

Getting the insurance adjuster to approve medical treatment can be frustrating

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 authorized treating physician.
  • The insurance company should also pay for medical testing ordered by the authorized treating physician.
  • 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 treatment that is not with an authorized doctor.  Treatment that is required because of an emergency is one example.  But, these exceptions are pretty limited.

What if the insurance company does not have a valid reason for denying your 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 approved

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 their voicemail when you call.  You may also find that your calls and emails are not returned.

If you or an attorney representing you communicates with the adjuster, it can solve many 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 hire an attorney, your attorney should help do this.

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 of medical treatment. This form attempts to solve the problem of the adjuster not responding at all when the doctor’s office is trying to get the treatment approved

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.  There are very special rules that have to be followed when a Form WC-205 is sent.

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 about the medical treatment.

This has helped a lot with trying to get medical treatment approved for our clients when we cannot get a response from the adjuster.  But, you have to understand a few things to make it work:

  1. What has to be done before you file the Form WC-PMT?
  2. What information you have to include when you file the Form WC-PMT?

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 JudgeA workers' compensation judge can order an insurance company to pay for medical treatment

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 get out of 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.

What if I have other questions about workers compensation?

Georgia’s workers compensation system can be very confusing.  You have to worry about getting the treatment you need and paying your bills while also worrying about not missing any deadlines that could cause you to lose your right to receive workers compensation benefits.

If you have questions, I would recommend that you try to get answers.  To find out more about how to schedule a time to talk to me about your workers compensation questions, just read this short article.

Jason Perkins is an attorney who specializes in representing injured workers.  He regularly publishes videos and write blog articles about Georgia’s workers compensation system and issues that are important to injured workers and their families. To be notified of Jason’s new workers compensation videos, subscribe to his Georgia Workers Compensation Video Series channel on YouTube by clicking the subscribe button below.

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Jason Perkins

Workers' Compensation Attorney

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