Every day our clients ask why their medical treatment is not being authorized.
The short answer is that the law in workers compensation with regard to medical treatment has become very technical, overregulated, and quite frankly complicated.
Every single case must be reviewed in the following manner:
1. IS THE INJURY DENIED?
If the injury being claimed is denied, workers compensation will not authorize any treatment until this issue is resolved. It is usually resolved after the injured worker has seen a neutral doctor, i.e. an agreed medical doctor or a panel qualified medical doctor.
2. IS THE BODY PART DENIED?
If workers compensation accepts that the injury caused is to one part of the body, but denies responsibility for another part of the body, they will not authorize any treatment for the denied body part until this issue is resolved. These resolutions are the same as number one above.
3. IS YOUR TREATING DOCTOR AUTHORIZED AS A PRIMARY TREATING PHYSICIAN, OR AN AUTHORIZED CONSULTANT OF THE PRIMARY TREATING PHYSICIAN
In a larger number of cases, when both the injury and the body part in question are accepted, the treatment still has to be by an authorized physician in a Medical Provider Network. Each workers compensation insurance carrier and or self-insured employer has the right to contract with a specific Medical Provider Network. The injured worker must carefully select from the proper network.
4. REQUEST FOR AUTHORIZATION FORM.
Each primary treating physician must make all request for medical treatment and prescriptions using a specific form created by the Workers Compensation Appeals board titled “Request For Authorization Form”. Failure to submit this form will probably result in no authorization of treatment. When this form is properly submitted, the date it is submitted is critically important because it begins the time periods listed below.
5. UTILIZATION REVIEW
If the workers compensation carrier does not authorize the treatment requested in the “Request For Authorization Form”, they have five business days to issue a “Utilization Review Determination”. These determinations are issued by separate companies with whom the workers compensation carrier has contracted. If the determination states that the requested treatment is not authorized, it must state the appropriate medical treatment guideline upon which this opinion is based.
6. INDEPENDENT MEDICAL REVIEW
Within 30 days of the receipt of a Utilization Review Determination denial, the injured worker, on a form prescribed by the state of California, which must be attached to the denial, must request Independent Medical Review. Independent Medical Review is performed by a company named Maximus with whom the state of California has contracted. When the request for Independent Medical Review is received by the Medical Unit of the State of California, under the current proposed regulations they have 15 days to determine if this case is eligible for Independent Medical Review. If there is eligibility, Maximus has 30 days to issue a written decision as to whether or not the treatment requested should be authorized. If the decision of Independent Medical Review denies the authorization, there are very few grounds for appeal. There is no statutory right to judicial review which means that you cannot go to court and present these issues to a workers’ compensation judge.
CONCLUSION:
Every single request for medical treatment even if it is for aspirin or three physical therapy visits must go through the above process.
At the time of this article, more request for medical treatment than ever before are being denied. It has become a statewide crisis. I’m sure that from what you have read above, you can see why this has occurred.
While we want you to know that we are very carefully monitoring each step of the above procedures in your case, we also want you to know why it takes so long for treatment to be authorized if at all.
