One of the most surprising problems many people encounter in workers compensation is difficulty getting the medical treatment they need. Medical treatment for your injury is one of the main things that workers compensations is supposed to cover. But, many people have difficulty getting the treatment their doctor recommends.
Your workers compensation doctor recommends treatment for your injury. This treatment may be physical therapy, an MRI, some medication injections or surgery. Unfortunately, and the insurance company does not necessarily approve that treatment.
When the insurance company does not give the doctor approval for that treatment, then the treatment is probably not going to happen because the doctors office wants to know that they are going to get paid. Not getting the treatment you need can be very frustrating. You probably want to be able to get treatment and get better.
How do you get treatment approved when the insurance company is not approving it?
There are a few different ways that you can try to do this:
- Contact the insurance company and speak with your adjuster or case manager
- Filing a Form WC-PMT
- Get your doctor to file a Form WC-205
- Filing a motion or requesting a hearing
Contacting the adjuster
The adjuster is the person who makes decisions about your case for the workers compensation insurance company. Your doctor usually will try to get approval from the adjuster for the medical treatment and testing that you need. But, you can try to get approval as well or have your attorney work to get approval if you hire an attorney.
Most doctors offices want to receive approval for the treatment from the adjuster. Sometimes, an adjuster just needs to receive certain information to approve the treatment. I often talk to adjusters to find out what information they need to approve the treatment my clients need.
Filing a Form WC-PMT
Unfortunately, talking to the adjuster is not enough. The adjuster may still not approve the recommended medical treatment. Fortunately, you or an attorney representing you can take other steps to get medical treatment approved.
The Form WC-PMT is one way to do this. This form was created to get an answer about approval of medical treatment when the insurance company is not giving an answer.
You can file the form to ask the insurance company to make a decision about approving medical treatment. If no decision is made, a phone call is scheduled with a workers compensation judge where the insurance company has to explain why they are not approving the medical treatment that has been requested. The Form WC-PMT can be a helpful way for you or your attorney to use in moving forward and getting medical treatment approved.
Filing a Form WC-205
The Georgia State Board of Workers’ Compensation has another form to help get approval for medical treatment. The Form WC-205 was created to allow doctors to request approval for the treatment they recommend and to require the insurance company give an answer.
The insurance company is given five business days to respond to that form and either approve the treatment or deny it. If you or an attorney can get the doctor’s office to file the Form WC-205, this is an additional way that you can move forward with getting treatment approved if your doctor is willing to send that Form WC-205.
Filing a motion or requesting a hearing
A final way to get treatment approved is filing a motion or requesting a hearing. If you proceed with either of these ways, then a workers compensation judge will make a decision about your medical treatment and whether the insurance company should pay for it.
If you go the motion route:
- You or your attorney will file a motion,
- The insurance company gets a chance to object, and
- A judge will make a decision.
If you go the route of requesting a hearing:
- A hearing will be scheduled in front of a workers compensation judge,
- You or your attorney will have an opportunity to present evidence at the hearing that basically explains why your treatment should be approved,
- The insurance company will also have an opportunity to present evidence at the hearing, and
- The judge will make a decision at the end of that hearing.