My Workers' Compensation Treatment was Denied. What Do I Do Now?
Dealing with a workplace injury is tough enough, but receiving a denial for your workers' compensation treatment can be overwhelming. Workers’ compensation is meant to provide the necessary medical care to help you recover and get back on your feet. When treatment is denied, it might feel like the system is working against you. Fortunately, a denial isn't the end of the road. In this blog, we’ll guide you through the steps you can take if your workers' compensation treatment has been denied.
Understand Why Your Treatment Was Denied
The first step in addressing a workers’ compensation denial is understanding why it happened. Denials can occur for a variety of reasons, and the explanation is typically outlined in the denial letter you receive. Common reasons include:
Incomplete Medical Documentation: The insurance company may claim they don’t have sufficient medical records to approve the treatment.
Utilization Review Denial: An evaluation by the insurance company’s medical reviewer may have determined that the treatment is not “medically necessary.
Pre-existing Condition: The insurer might argue that your condition is related to a pre-existing injury, not the workplace incident.
Once you know why the treatment was denied, you and your attorney can focus on addressing the specific issues raised by the insurance company.
Work with Your Doctor to Appeal the Denial
If your treatment was denied due to insufficient medical documentation or a utilization review, don’t lose hope. One of the most effective ways to challenge the denial is by working with your doctor to gather more evidence. Here’s how you can do this:
Request Additional Medical Records: Ensure that your doctor sends all relevant medical records to the insurance company. Sometimes, crucial details may be missing from your initial submission.
Engage in Peer-to-Peer Review: Your doctor may participate in a peer-to-peer review with the insurance company's physician. This allows your doctor to explain why the recommended treatment is medically necessary and appropriate for your condition.
Submit an Appeal: If the insurance company still refuses treatment after the peer review, your doctor can formally appeal the denial. This will require additional documentation that emphasizes the need for the treatment.
In many cases, insurance companies reverse their denial once they receive more detailed information from your healthcare provider.
Seek Legal Assistance to Challenge the Denial
If your doctor’s efforts don’t resolve the issue, it’s time to take more formal action. An experienced workers’ compensation attorney can be a critical ally in helping you challenge the denial. Here’s what an attorney can do:
Request a Hearing: If the insurance company won’t budge, your attorney can request a hearing before an arbitrator. At this hearing, your attorney will present evidence, including medical records and testimony from your doctor, to demonstrate that the treatment is necessary for your recovery.
Navigate Legal Complexities: Workers’ compensation laws are complex, and insurance companies often exploit these complexities to their advantage. An attorney will know how to navigate the system, ensuring that your rights are protected and that you receive the treatment you need.
Ensure Compliance with Legal Deadlines: Filing appeals and requesting hearings come with strict deadlines. Missing a deadline could cost you your chance to receive treatment. Your attorney will ensure that everything is filed correctly and on time.
Receiving a denial for workers’ compensation treatment can be discouraging, but it’s important to remember that you have options. By understanding the reasons behind the denial, working with your doctor to gather additional evidence and enlisting the help of a skilled workers’ compensation attorney, you can fight for the care you need. Don’t let a denial stand in the way of your recovery— take action today to protect your rights!
At Black & Jones Attorneys at Law, we have years of experience helping injured workers in Rockford, IL, get the benefits and treatment they deserve. Contact us for a free consultation to learn how we can assist you in fighting a workers' compensation treatment denial.