When Work Comp Denies the Treatment You Need

Have you received a letter from the worker’s compensation insurance carrier telling you that they are denying approval for medical treatment recommended by your doctor? You need to know that their “decision” is not necessarily final. Insurance companies deny treatment for several reasons. Sometimes it is simply because they do not have the complete medical records from your doctor showing what your diagnosis is and explaining what his recommendations are for treatment. This is easily addressed by asking the doctor to send the records to the adjuster. Many times, clients will come to Black & Jones and say that their doctor has sent the records to the adjuster but the adjuster claims they never received them. At Black & Jones, we get the records from the doctor for you and we send them to the adjuster so that we have proof that the documents were sent and received. If they still play games and deny treatment, then we file a request for hearing and drag them before the Arbitrator to explain why they haven’t approved treatment.

Sometimes the denial letter will indicate that the treatment is not approved because it was not “certified” by utilization review. This can be confusing but is not hard to correct. Under Section 8.7 of the Illinois Workers’ Compensation Act, the insurance company can have a company that is registered and URAC certified do an “evaluation of the proposed or provided health care services to determine the appropriateness of both the level of health care services medical necessary and the quality of health care services provided to a patient.” The process has very strict rules to be compliant with the law. For example, the review must be done by a physician who is similarly licensed as your doctor and must be reviewed in light of nationally recognized treatment guidelines and must set forth the clinical rationale for the decision. Once you receive a non-certification, it is important to have your doctor appeal it. Oftentimes, the denial is based on the lack of documentation in the records your doctor provided. In that situation, once your doctor engages in peer to peer review with the provider doing the utilization, the doctor can often convince the reviewer that the treatment is medically necessary. If your doctor will not do the appeal or the insurance company will not change its decision, call Black & Jones. We will make sure the necessary steps are taken to get the decision changed or we will proceed to trial to prove to the arbitrator that the treatment is medical necessary to address your work injury. Call us today for a free consultation!