Getting Physical Therapy Paid For By Workers Compensation
Physical therapy, or PT for short, is a fairly common treatment ordered by doctors in a number of injury situations. Doctors prescribe physical therapy as medical treatment for many different types of injuries that occur at work.
It is one of the most common types of medical treatment in a workers compensation claim. Sometimes, your doctor will order physical therapy right after an injury. Your doctor also may order physical therapy after performing a surgery to help you recover from that surgery and build back your muscle strength.
If you need physical therapy because of a workers compensation injury, the basic idea is that workers compensation covers that medical treatment. Of course, you must follow some basic rules to get that treatment covered.
An authorized treating doctor must order the physical therapy. Also, Georgia workers compensation law now has a 400 week limitation on medical treatment in most cases. These are just a couple of the requirements.
Workers compensation should cover the physical therapy if you meet those requirements. But, some workers compensation insurance companies delay or deny your physical therapy anyway.
Since physical therapy is pretty routine treatment, why would I have difficulty getting it approved?
Years ago, insurance companies almost always approved physical therapy when the doctor ordered it. However, insurance companies have started fighting about physical therapy a lot more in recent years.
Here is what happens a lot. You see your doctor for an office visit, and your doctor orders your physical therapy. Someone at the doctor’s office either tells you that they will set it up or tells you to take it to a physical therapy provider to set it up.
A week later, your physical therapy has still not been scheduled. The most common cause is that it will not be scheduled until the insurance company gives approval.
How does the workers compensation insurance company deny physical therapy?
Usually, the physical therapy office will want to get approval form the insurance company to treat you before scheduling your physical therapy. The physical therapy office wants to know they are going to get paid for the work they do.
The insurance company can deny your treatment in two basic ways:
- They actually deny your treatment. The insurance company does this by filing a Form WC-3 Notice to Controvert or by telling the physical therapy office that they are denying the request for treatment
- They do not give approval for the treatment (although they do not actually deny it)
It is probably office what happens if the insurance company denies treatment. They refuse to pay for it so the physical therapy office will probably not schedule the treatment. You will probably need to get some help to make the insurance company pay for the physical therapy.
But, what happens when the insurance company does not deny the treatment but just does not give approval? Unfortunately, the effect on you is pretty much the same because you do not get the physical therapy recommended by your doctor. Remember, many medical providers do not want to schedule treatment unless they know they are going to get paid for it.
What if the insurance company does not approve as much physical therapy as the doctor ordered?
One other thing that you have to watch out for is a partial approval. This happens a lot with physical therapy. Your doctor may order a certain amount of physical therapy, but the insurance company does not approve the full amount.
Take this example. The doctor orders physical therapy three times a week for 4 weeks. The insurance adjuster approves physical therapy two times a week for four weeks.
This is an example of partial approval. Partial approval is really a partial denial because the insurance company has denied part of the doctor’s recommendations. Because of that, you should consider treating it like any other denial of physical therapy.
What evidence does the insurance company need to deny my physical therapy?
It would be nice if there was a standard that said the insurance company has to approve the physical therapy unless they have certain evidence to deny it. Georgia law does not have that standard right now. So, the insurance company does not have to have certain evidence to deny or delay your treatment.
Sometimes, insurance companies will get utilization review opinions from a doctor or other medical provider saying that you do not need physical therapy. Other times, they will send questionnaires to the treating doctor or get a second opinion. The insurance company may also just refuse to provide approval without getting any evidence at all.
Whether the insurance company gets evidence or not, the result to you is the same. You face an obstacle getting your treatment.
What can I do to get my physical therapy approved?
The first step is to talk to the physical therapy office. You want to find out what they have done. Have they requested approval? If so, have they received any answer from the insurance company?
Often, your next step will be to contact the insurance adjuster to ask them to approve the physical therapy. Hopefully that will correct the situation, but the insurance adjuster may refuse or give an excuse.
If this happens, you may need to do more. When the insurance company does not pay for physical therapy voluntarily, you can take measures to force them to pay for that treatment. Some of the measures you can take include:
- Filing a motion or a Form WC-PMT to get the treatment approved
- Asking the doctors office to file a Form WC-205 requesting approval
- Requesting a hearing in front of a judge to get approval
Sometimes, you have to go one of these routes to get approval. If you do, I would suggest that you talk to an attorney to find out the best option for you and to decide if you need to hire one to pursue one of these options.
Some people have concerns about the cost associated with talking to or hiring an attorney. Our law firm tries to address that concern in two ways:
- We provide free, no obligation consultations so you can get the information you need without worrying about cost. Just read this article to find out how those free consultations work.
- If you decide to hire us, we work on a contingency fee contract which means you don’t pay us unless we recover money for you. This article explains how a contingency fee contract works in more detail.
If you would like to set up a free consultation with me, just call our office at (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 publishes videos and write blog articles about Georgia’s workers compensation system and issues that are important to injured workers and their families.
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