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Getting Workers Compensation Surgery Approved

You rightfully expect that the insurance company would pay for the medical treatment you need when you get hurt at work.  You would also expect that your workers compensation doctor would be the one making decisions about what treatment you need.

Unfortunately, this often does not happen.  One of the things that most people get frustrated with in Georgia’s workers compensation cases is the insurance company refusing to pay for a surgery their doctor recommended.

You may have to fight for the surgery your doctor recommends. Understanding why insurance companies do this can help you get the medical treatment you need.

Male doctor shows female patient xray of spine and backWhy would the insurance company refuse to approve my surgery?

Insurance companies have different reasons that they refuse to pay for surgery.  But, the biggest reason they refuse to pay for surgery is probably believing that they save money.

Workers compensation insurance companies are businesses.  Like most businesses, they are in business to make money.

A workers compensation insurance company makes money by receiving insurance premiums from employers.   Just like you pay an insurance premium on your car or your house, employers pay premiums for workers compensation insurance.  Our law firm, as a business, pays premium to an insurance company to provide workers compensation coverage for our employees.

In exchange for the payment of these premiums, the insurance company agrees to pay benefits when certain things happen.  In the case of workers compensation, the insurance company is providing insurance for work-related injuries.

This means that the insurance company has to pay out money when you get hurt at work.  This costs them money.  If they pay out less to somebody when an injury occurs at work, then they make more money.

Surgery can be expensive.  So, avoiding paying for a surgery can save an insurance company a lot of money.

Now, I am not saying that insurance companies are necessarily being unreasonable when they refuse to pay for surgery. What I am saying is many of them believe that refusing to authorize surgery and other expensive medical treatment saves them money.

Unfortunately, this means you may have to fight or have someone fight on your behalf to get the medical treatment you need.

Why will the workers compensation doctor not schedule my surgery without approval of the insurance company?

Georgia workers compensation law does not require doctors to have approval for surgery or any other medical treatment prior to performing it.  But, it is very difficult if not impossible to get a workers compensation doctor to perform surgery without approval from the insurance company.

There is a good reason for this.  Doctors and other medical providers want to get paid for the work that they do.  If they perform treatment without approval from the insurance company, they take the risk that the insurance company might controvert the medical treatment they performed for some reason.

A controvert is just a fancy word for “deny”.  If the insurance company controverts the treatment, then the doctor runs the risk of not getting paid for the work that they did.

What can I do to get my surgery approved by the workers compensation insurance company?

Ultimately, the reason the insurance company refuses to approve the surgery will not necessarily matter to you.  What matters is that you get the medical treatment your doctor says you need.

There are several different ways to get approval for a surgery when the insurance company denies it.  The best method for getting your surgery approved will depend on the particular facts of your case.

Talk to the insurance adjuster

The insurance adjuster should have the authority to approve or deny your surgery.  This means that the insurance adjuster probably made the decision to deny your surgery.  Sometimes, insurance adjusters can be persuaded to change their minds and approve a surgery that they have previously denied.

The insurance company may just not have a good understanding the surgery: Some common confusion that insurance companies have about surgeries include:

  • What exact surgery the doctor is recommending
  • Why exactly the surgery is needed
  • How the surgery is related to your injury at work

You or an attorney may have to provide the insurance adjuster with additional information to show the adjuster these things.  The insurance adjuster may also want a second opinion with another doctor before approving the surgery.

Man reading letter on couch

File a Form WC-PMT

Sometimes, you cannot get in touch with the insurance adjuster to get them to change their mind.  Other times, you get in touch with them but they will not change their mind.

The Form WC-PMT (Petition for Medical Treatment) is a relatively new Georgia State Board of Workers’ Compensation form.  It was created a few years ago to help solve the problem of insurance companies delaying treatment.

You have to follow certain rules to file a WC-PMT.  But, when a WC-PMT is properly filed, it requires the insurance company to give an answer about whether they are authorizing or denying your treatment.  If they do not give an answer, there is a phone call with a workers compensation judge about the recommended medical treatment.

Our office uses this form a lot to get medical treatment approved for our clients.  Whenever a workers compensation doctor orders treatment, we start taking the steps that are necessary to file a WC-PMT.  The first part of that process is communicating with the adjuster about the medical treatment recommended.  But, if the adjuster does not approve that treatment within a week or so, we move forward with filing a WC-PMT.

Get the doctor to file a Form WC-205

The Form WC-205 is an older State Board of Workers’ Compensation form.  Your workers compensation doctor can use this form to request approval for medical treatment.

The advantage of this form is that State Board rules require the insurance company to give an answer within five business days.  If the doctor’s office follows the rules and the insurance company fails to respond in time, then the medical treatment should be authorized.

File a motion or request a hearing

Another option for getting surgery treatment approved involves getting the issue before a workers compensation judge.  A judge can also get involved through the WC-PMT process mentioned above, but the insurance company can avoid the judge getting involved in that process by authorizing or denying the treatment.

Motions or hearing requests can help to get treatment approved.  A motion or hearing request can result in an order from the judge approving surgery.

Of course, there is no guarantee that the judge rules in your favor.  You also have to consider the time it takes to get a ruling on a motion or to receive an award after a hearing.

What if I have other questions about workers compensation?

Georgia’s workers compensation system can be very confusing.  You have to worry about getting the treatment you need and paying your bills while also worrying about not missing any deadlines that could cause you to lose your right to receive workers compensation benefits.

If you have questions, I would recommend that you try to get answers.  To find out more about how to schedule a time to talk to me about your workers compensation questions, just read this short article.

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.

To be notified of Jason’s new workers compensation videos, subscribe to his Georgia Workers Compensation Video Series channel on YouTube by clicking the subscribe button below.

Brittney-lee orourkeBrittney-lee orourke
05:23 18 Feb 22
Amazing! Jason and his team were very helpful and had the best communication by far. Walked me though every step with great detail and had answers for any question I had. They handled my case better then I could imagine, it was a weird case and they stayed on top of it and kept me updated every step of the way! Highly recommend this Team! Thanks so much to Jason and his Awesome team!-Brittney
China JonesChina Jones
18:58 08 Feb 22
I absolutely love this group of attorneys, when I was at my lowest they did everything they could to help me get justice for my injury. I believe if I were to have never picked my phone up and called the amazing group that helped me I definitely would not have received my idea of rights. If you have an issue and are just not sure please understand that they will help you, stay in contact, answer any question you have, and for sure get you the justice you deserve I thank them from the bottom of my heart and I will definitely refer them to anyone who has been hurt because they most definitely care about their work and clients.
Luv LocsLuv Locs
16:08 15 Jan 22
The entire law office was attentive and responsive to all of my concerns dealing with my workers compensation case.
moombimoombi
21:14 02 Jan 22
If you must get a lawyer involved, you’d do well to work with Jason Perkins and his team at Perkins Studdard Law.They were thorough in gathering information and in sharing all the steps in the workers comp process specific to my case. Jason and the team were responsive to my bevy of questions and concerns.I appreciated the informative videos and consultations provided by Jason over video meetings and multiple phone calls.I hope I’m never injured on the job again. However, if I am and if my employer responds as my previous employer did, I’ll contact Perkins Studdard Law immediately to handle the case.
Dana BessDana Bess
23:57 10 Dec 21
Everyone at Perkins Studdard was kind and professional. They were always extremely responsive and answered all questions that I had and followed up to make sure I had an understanding of what was going on along with emailing videos to explain every step of my case so I would know what to expect and be prepared. Jason is a very genuine person and I trusted him with my case. He answered so many questions for me even before I retained him as my WC lawyer. I highly recommend him and his associates at Perkins Studdard.
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