Your doctor ordered an MRI to diagnose your injury. But, the workers compensation insurance company has not authorized the MRI.
So, you are stuck in limbo. You need treatment to get better. You cannot get that treatment until the doctor can get the MRI done and diagnose your injury.
In the meantime, you may be unable to work or to do the things that you need to do at home. What do you to get the treatment approved and ?
Unfortunately, I hear about these problems with workers compensation approving medical testing and treatment much more often than I used to. It seems like insurance companies make it more difficult to get what should be relatively simple treatment or testing for your injury. This article will discuss some of the reasons that MRIs and other testing gets delayed and what you can do about it.
What is an MRI?
MRI is an abbreviation for Magnetic Resonance Imaging. It is a test ordered by a doctor to get a better internal picture of a particular part of your body. MRIs often help doctors diagnose injuries and illnesses and make treatment recommendations.
In workers’ compensation cases, doctors often order MRIs to determine how badly you have been injured. Some of the most common workers compensation MRIs include:
- MRIs on your back or your neck which help doctors determine whether you have suffered a herniated disc or pinched nerve;
- Shoulder MRIs which help doctors diagnose rotator cuff and ligament tears and other types of shoulder injuries;
- Knee MRIs which can show a torn anterior cruciate ligament (ACL) or a torn meniscus, among other things.
If my doctor says I need an MRI, why does it not get approved?
Unfortunately, your doctor ordering the MRI does not always mean that it is going to happen quickly in a Georgia workers compensation case. Most MRI testing facilities will want the insurance company to approve the MRI before they schedule an appointment for you. The reason for this is that medical providers want to know they are going to get paid for their services before they move forward with treatment or testing.
Sometimes, the doctor orders the MRI and everything works how it should. You receive a call a few days later that it has been scheduled. This call may come from the workers compensation insurance company or a contractor hired by the insurance company to schedule the appointment.
But, the MRI will probably not get scheduled if the insurance company does not approve it. This can be very frustrating for the reasons I mentioned earlier.
The workers compensation system was not set up to work this way. It was set up to provide the medical treatment and testing you need for your work injury in a timely manner.
Why is this delay happening?
Several things can cause this delay:
- The workers compensation coordinator at the doctor’s office or MRI testing facility cannot get an answer from the insurance adjuster about the MRI being approved
- The insurance adjuster says that they need time to “review the file” before making a decision about approving the MRI
- The insurance company wants a second opinion from another doctor before approving the MRI
- The MRI is denied by the insurance adjuster
- The insurance adjuster sends the MRI request to utilization review
Often, all you may know is that the doctor said you need an MRI and the MRI has not been scheduled yet. You do not know why the MRI has not happened unless you or an attorney representing you do some research. If you do not have anyone helping with your case, you may wait weeks or longer before anyone even tells you that there is a delay in getting your MRI scheduled.
What can I do to get the MRI approved?
Delay and denial of medical treatment is a serious problem in many Georgia workers compensation claims. You would like to get the treatment you need as quickly as possible so that you can get out of pain and move on with your life.
You or an attorney may have to do some things and step in to try to get the MRI approved. A good first step is to contact the doctor’s office or the facility where the MRIs going to be performed. They should be able to tell you what the status of scheduling the MRI is.
If they indicate that they are waiting on approval, try to find out what has been done so far to get approval.
- Has the medical facility called the adjuster to get approval for the MRI? If so, were they able to speak with the adjuster or did they get voicemail?
- Did the medical provider email the adjuster to try to get approval? If so, was there a response and what did it say?
- Has the workers compensation insurance company denied the MRI or have they just not given an answer?
If the MRI is not being approved because the adjuster is delaying things, then you may need to contact the adjuster directly.
If you have an attorney representing you, then that attorney should take care of that for you. But, you may need to let your attorney know that the MRI has been ordered but has not been scheduled yet.
What if the adjuster still does not approve my MRI?
If you have an attorney, talk to them to find out the best strategy for getting the MRI approved. If you do not have an attorney, you can take additional steps to get the MRI approved. Some of your options include:
- Getting the doctor to send a Form WC-205
- Filing a Form WC-PMT
- Filing a motion with a judge to get the MRI approved
- Requesting a hearing in front of a workers compensation judge
Some of the processes mentioned above (like going to a hearing) often take much longer than some of the other process (like filing a Form WC-PMT. But, the best process to use to get an MRI or other medical treatment or testing approved will depend on your specific situation.
While you can try to take these steps yourself, I would certainly recommend talking to an attorney if you reach this point. There are special rules and procedures that you need to follow under Georgia’s workers compensation law.
Following these rules helps maximize the changes that you will receive the workers compensation benefits you should. An attorney who specializes in workers compensation can be very helpful to you in making sure you follow those rules and also picking the best strategy to pursue to get your MRI and other treatment and testing approved.