After weeks or months of treatment, your workers compensation doctor tells you that you need surgery. That can be frightening because no one wants to have surgery.
If you decide to move forward with the recommended surgery, the doctor’s office should schedule it. But, that often does not happen in workers compensation cases because the insurance company often fails to approve the surgery recommended by your doctor.
This is extremely frustrating. You just want to get the treatment your doctor recommended so that you can feel better. Now, you find yourself stuck waiting for an adjuster to give the doctor’s office the green light before they will move forward with the surgery you need.
Why does the doctor’s office need approval from the insurance company?
Technically, the doctor’s office does not need insurance approval. The doctor’s office can just perform the surgery and bill the insurance company. Georgia’s workers compensation laws say that preapproval is not required for medical treatment or testing.
But, this will not happen. The reason that it will not happen is that the doctor’s office wants to make sure they get paid for the work they do. So, they will want approval from the insurance company for the surgery before moving forward and performing it.
The problem with this approach is that you get stuck in the middle. The surgery that you need does not get performed until the insurance company gives that approval to the doctor’s office.
This does not make a lot of sense. After all, the doctor has trained for years to know what medical treatment is appropriate. The insurance adjuster does not have anything near the medical knowledge that the doctor has.
Unfortunately though, you are stuck in a workers compensation system where the doctors are not going to move forward without insurance company approval. So, what can you do about this?
How can I make the insurance company approve my workers compensation surgery?
There are several different steps that you can take to get approval for the surgery.
- Contact the doctor’s office to find out the status of the surgery being approved
- Communicate with the insurance adjuster to get the adjuster to give the doctor’s office approval for the surgery
- File a Georgia workers compensation form such as a Form WC-205 or Form WC-PMT
- File a motion to ask a judge to order the surgery
- Request a hearing in front of a workers compensation judge regarding the surgery approval
The best step to take will depend on the particular facts of your case. Sometimes, it will be better to communicate with the doctor’s office or the adjuster. Other times, it will be better to file a Form WC-PMT or request a hearing. You may even need to take a multi-pronged approach where you are working on more than one of these things at the same time.
Will hiring an attorney who specializes in workers compensation help get my surgery approved more quickly?
There is a good chance it will. Unfortunately, I see way too many people who have their treatment delayed for months without even really making any progress toward approval. An attorney who specializes in workers compensation can help out in several different ways:
- Determining which is the best approach to take first to try to get approval
- Evaluating if that approach is working and figuring out which approach to take next if that does not work
- Knowing how the system works and what needs to be done to get the surgery approved
- Understanding the rules that must be followed to be successful when filing workers compensation forms and motions and presenting a case successfully at a workers compensation hearing
This does not mean you have to hire an attorney. But, I would recommend that you speak with a workers compensation attorney if your surgery is being delayed or denied.
When someone schedules a consultation with me regarding delays in surgery approval, I try to answer their questions and let them know if I believe it would make sense to get me involved in their case.
