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Beating Insurance Company Medical Treatment Denials5 minute read

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.

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 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 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 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.

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.

Brittney-lee orourkeBrittney-lee orourke
05:23 18 Feb 22
Amazing! Jason and his team were very helpful and had the best communication by far. Walked me though every step with great detail and had answers for any question I had. They handled my case better then I could imagine, it was a weird case and they stayed on top of it and kept me updated every step of the way! Highly recommend this Team! Thanks so much to Jason and his Awesome team!-Brittney
China JonesChina Jones
18:58 08 Feb 22
I absolutely love this group of attorneys, when I was at my lowest they did everything they could to help me get justice for my injury. I believe if I were to have never picked my phone up and called the amazing group that helped me I definitely would not have received my idea of rights. If you have an issue and are just not sure please understand that they will help you, stay in contact, answer any question you have, and for sure get you the justice you deserve I thank them from the bottom of my heart and I will definitely refer them to anyone who has been hurt because they most definitely care about their work and clients.
Luv LocsLuv Locs
16:08 15 Jan 22
The entire law office was attentive and responsive to all of my concerns dealing with my workers compensation case.
moombimoombi
21:14 02 Jan 22
If you must get a lawyer involved, you’d do well to work with Jason Perkins and his team at Perkins Studdard Law.They were thorough in gathering information and in sharing all the steps in the workers comp process specific to my case. Jason and the team were responsive to my bevy of questions and concerns.I appreciated the informative videos and consultations provided by Jason over video meetings and multiple phone calls.I hope I’m never injured on the job again. However, if I am and if my employer responds as my previous employer did, I’ll contact Perkins Studdard Law immediately to handle the case.
Dana BessDana Bess
23:57 10 Dec 21
Everyone at Perkins Studdard was kind and professional. They were always extremely responsive and answered all questions that I had and followed up to make sure I had an understanding of what was going on along with emailing videos to explain every step of my case so I would know what to expect and be prepared. Jason is a very genuine person and I trusted him with my case. He answered so many questions for me even before I retained him as my WC lawyer. I highly recommend him and his associates at Perkins Studdard.
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