You rightfully expect that the workers compensation 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 medical treatment you need.
When a surgery recommendation happens, this means that your several things have already happened in your medical treatment:
The doctor has diagnosed your injury or illness with medical testing
The doctor has evaluated and/or tried other less invasive treatment options
The steps above may have taken weeks and months. When your doctor recommends surgery and you agree to move forward with it, you just want to get the surgery done and be on the road to recovery.
Unfortunately, your workers compensation insurance company may prevent this from happening. 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 that the workers compensation doctor recommended.
You may have to fight for the surgery your doctor recommends. You may need to get an attorney involved to fight on your behalf. Understanding why insurance companies deny surgery in the first place can help you figure out the best steps to take to get the medical treatment you need.
Why 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 a belief 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.
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 on the job. 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 approach by workers compensation insurance companies 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 just like you and I do. If they perform treatment without approval from the insurance company, doctors 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. So, to avoid this risk, almost all medical providers make sure they have approval from the insurance company before moving forward with treatment.
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 does not necessarily matter to you. What really 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 is the person assigned by the workers compensation insurance company to make decisions for them about your case. The insurance adjuster should have the authority to approve or deny your surgery.
The fact that your surgery has not been approved after some time could mean 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 about the surgery: Some common confusion that insurance companies have about workers compensation surgeries include the following:
What exact surgery the doctor is recommending
Why exactly the surgery is needed
How the surgery is related to your injury at work
Why other more conservative treatment options do not need to be tried first
Sometimes, you cannot get in touch with the insurance adjuster to get them to change their mind. You call and get voicemail. You text and email with no answer.
Other times, you get in touch with the adjuster and present them with information that they need. But, the adjuster still will not change their mind.
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. The first part of that process is communicating with the adjuster about the medical treatment the doctor recommended. This is a requirement of filing the WC-PMT. When this process does not work, filing the WC-PMT is often our next step..
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.
In some situations, the Form WC-205 can be very helpful because it gives answers about treatment quickly. But, there are downsides to it as well. One thing that often needs to be considered is whether it is better to try to file a Form WC-PMT or a Form WC-205.
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.
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.
Depending on how long it takes to get to court and whether the case is appealed or not, it can take months or even years to get a final enforceable decision from a workers compensation judge. This makes it extremely important to consider the best approach for getting your surgery approved. Deciding on the best approach requires a detailed understanding of Georgia’s workers compensation laws.
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.
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
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.
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.
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.
