Can I Fight Workers Compensation Utilization Review?
If you are reading this article, you have probably had some medical treatment recommended by your doctor in a workers compensation case. Then you received a letter or an email from Coventry notifying you that the medical treatment was not certified.
Your first question was probably, “What in the world does this mean?” Most of these letters have a lot of official sounding language in them about:
- Your work injury and medical treatment;
- Some medical guidelines that say when treatment is appropriate; and
- Attempts by a doctor to contact your doctor to discuss the treatment that is recommended
Can you still get the treatment that your doctor recommended?In this article, I am going to discuss what these letters mean in Georgia workers’ compensation cases and how you might get the medical treatment you need.
What is Coventry?
Coventry is a large company that does a lot of workers’ compensation business. When you received the “Notification of Non Certification” from Coventry, you have encountered that company in the utilization review or peer review process.
The basic idea of utilization or peer review is to have a medical provider review the recommendations made by another medical provider. In this review, they try to determine whether these recommendations are appropriate.
If you received the “Notification of Non Certification”, Coventry has probably conducted a prospective utilization review of the medical care recommended by your doctor or other medical provider.
What does all that language in the Notification of Non Certification mean?
The Notification of Non Certification and other utilization review documents generally contain information explaining why the recommended treatment is certified or not certified.
This letter from Coventry probably had some information from a doctor and a nurse about the treatment that was recommended. It may have referred to the Official Disability Guidelines or some other set of guidelines.
This language supports the non-certification decision. It states the reasons for why Coventry is not certifying the treatment or testing recommended by your doctor.
If I received the “Notification of Non Certification”, does this mean that the insurance company is denying my treatment?
Not necessarily. Coventry is generally separate from the insurance company handling in your case.
Most of these non certification letters or other utilization review documents will have some sort of language indicating that your claims examiner or adjuster will make the decision about whether to approve treatment. They may say something like, “The claims handler or representative will make the final decision about approval of medical treatment”.
Many insurance adjusters do have authority to override utilization review determinations. Whether they will use that authority to override the utilization review denial is a separate question though.
Often, most insurance companies will refuse to authorize medical treatment if the utilization review indicates that the treatment should not be certified or approved. But, I have had many times where a conversation with the adjuster has gotten the treatment authorized.
If the insurance company denies my medical treatment, what can I do about it?
Denial of medical treatment by insurance companies is one of the most frustrating parts of Georgia’s workers’ compensation system. After you have suffered an injury, you just want to get better. When the insurance company delays and denies your medical treatment, you cannot get better.
You can take steps to fight back. This article I wrote provides some information about how you can overcome medical treatment denials and get the treatment you need.
Often, you may have to convince an adjuster to provide the treatment you need. If the adjuster refuses, you probably will need to request a hearing. A workers compensation judge can order the insurance company to pay for the medical treatment you need.
This can be very tricky. If the insurance company delays or denies your medical treatment. you should strongly consider a consultation with a workers compensation attorney to find out what options you have.
Many people worry that it will be expensive to discuss their case with an attorney. I provide free consultations in workers compensation cases so that you do not have to worry about the cost. If you would like to set one up, just call (770) 214-8885 or complete and submit the “Need Help” form on this page.
Jason Perkins is an attorney who specializes in representing injured workers. He regularly blogs about Georgia’s workers’ compensation system and issues that are important to injured workers and their families.
You can subscribe to his Georgia Workers Compensation channel on YouTube.