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
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.
File a Form WC-PMT
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.
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. It has been quite helpful in certain situations in solving these problems.
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.
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.
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.