Georgia’s injured workers too often cannot receive timely medical treatment for their work injuries. When your treating doctor recommends certain medical treatment, you should not have to wait months or longer to get that treatment.
Unfortunately, insurance companies have taken advantage of a system which allows them to delay and deny workers compensation medical treatment. The Georgia legislature and the Georgia State Board of Workers’ Compensation create the rules that apply to Georgia’s workers compensation system.
The Georgia legislature did not pass any new laws that affected workers compensation medical treatment in 2017. But, the Georgia State Board of Workers’ Compensation passed changes to its rules in June 2017. One of those changes creates a new method for trying to get medical treatment authorized by an insurance company.
What is the new rule about authorization of medical treatment?
The State Board made changes to Board Rule 205 which was an existing rule. Board Rule 205(c) now contains the new method to get medical treatment authorized. That method uses a new Board Form called a WC-PMT to request authorization for treatment.
Basically, this form allows an injured worker or the injured worker’s attorney to request a conference call with a workers compensation judge about approval of medical treatment. The rule does not apply if the employer is providing medical through a Board certified WC/MCO. Also, the rule does set out particular requirements for use of the form:
- An authorized treating provider has recommended medical treatment or testing
- The employer/insurer has been provided documentation of the recommendation for at least 5 business days but have not authorized the treatment or testing
If these requirement are met, the injured worker or attorney can file the WC-PMT form. This is one advantage of this new system as opposed to the Form WC-205 where the medical provider had to sign the form.
What happens when the form is filed?
After the form is filed, the State Board should issue a “Notice of Telephonic Conference”. This means that they will schedule a time for a phone call with the workers compensation judge.
The State Board will schedule that phone call not more than five business days from when the WC-PMT is filed. All parties can participate in the call by dialing into the phone number indicated on the Notice of Telephonic Conference.
Delay in approval of medical treatment is one of the biggest problems for injured workers. The good news is that this phone call will happen quickly and can only be postponed for good cause.
Also, the party needing a postponement must get a date that is agreeable to the opposing party that is within five business days of the original date. This means that the phone call should happen no later than 10 business days from when the WC-PMT petition is filed.
What happens after the telephonic conference?
After the telephonic conference, the workers compensation judge can order the insurance company to contact the medical provider and provide authorization for the medical treatment or testing. If the judge issues an order, either party can appeal that order by requesting a hearing within 20 days.
Board Rule 205(c)(4) and (5) indicate that the order becomes effective if neither party appeals. When the order becomes effective, the employer or insurance company consents to pay for the ordered medical treatment pursuant to the workers compensation fee schedule.
Can the insurance company cancel the telephonic conference?
Yes, in a way. The insurance company has two options for cancelling the telephonic conference.
- They can complete Section C of the WC-PMT to authorize the requested medical treatment or testing
- They can complete Section D of the WC-PMT to controvert (deny) the request medical treatment or testing
Rule 205(c)(3) indicates that the telephonic conference will be cancelled when the employer or insurance company does either of these two things.
Why do I need authorization of medical treatment?
The Georgia workers compensation law still does not require advance authorization of medical treatment. In fact, Board Rule 205 specifically states that advance authorization is not required.
However, getting medical treatment without advance authorization is next to impossible in most situations. Medical providers want to know that someone will pay them for the treatment they perform.
Because of that, many medical providers will not provide medical treatment without someone agreeing to pay for treatment. This often means that you either need to get the insurance company to provide authorization or agree to pay for the treatment yourself.
If you do not get the insurance company to authorize the medical treatment, you often wait weeks or months to get that medical treatment. Sometimes, you never get it at all. That is why Georgia needs a good system to get workers compensation medical treatment authorized.
Does the insurance company have to file any paperwork when they deny my medical treatment?
There is not a clear answer to this question. In Georgia, insurance companies normally file forms published by the Georgia State Board of Workers’ Compensation when they take certain specific actions on your case.
When they start or stop paying your weekly benefits, the insurance company should file a form. They should file a form when they deny your claim.
But, insurance companies often do not file any forms when doctors request medical treatment. So, you will often not know whether the treatment is being approved, denied, or just delayed.
The WC-PMT form attempts to address this somewhat. It indicates that the insurance company will complete Section D if they controvert the medical treatment or testing. Board Rule 205 also says that the insurance company does not have to file any other form when they complete that section.
Will the changes to Board Rule 205 solve the medical treatment authorization problem?
I do not know. It is certainly nice that the rule provides a method to try to get medical treatment approved quicker. Instead of waiting months to get before a workers compensation judge to try to get surgery or some other medical treatment approved, you should have a conference call within two to three weeks.
Of course, the conference call does not mean that the treatment will be approved. Also, the insurance company can still request a full blown hearing to appeal the judge’s order after the conference call.
If a hearing is requested, you will probably find that your medical treatment is delayed many more months while you wait for the hearing. If most insurance companies take the approach of requesting hearings to appeal the telephonic orders, the new process may not provide much of a solution to the medical treatment delay problem.
Can I still use the Board Form 205 to request authorization of medical treatment?
Yes. When the State Board of Workers’ Compensation changed Board Rule 205, they still left in Board Form WC-205 as a method for requesting medical treatment or testing.
Do I need a workers compensation attorney to file a Form WC-PMT and request a telephonic conference?
No. The changes in Board Rule 205 clearly state that an injured worker or the injured worker’s attorney can file the form to request the telephonic conference. So, you can file the form yourself.
You should consider that the insurance company will likely try to have their workers compensation attorney participate in the phone call with the judge. Because of that, it could certainly make sense to have an attorney representing you as well. Also, you will probably need an attorney if the insurance company requests a hearing to appeal the order from the workers compensation judge.
Before you make the decision about whether you should hire an attorney to represent you, you should get a consultation with an attorney to discuss what is going on with your case and what an attorney could do for you.