Why Does it Take So Long for Insurance to Approve Treatment?

When you hurt your hand at home, you usually can call your doctor’s office and get into see someone fairly quickly. Then if the doctor recommends a diagnostic test or physical therapy, you can call the place you want it performed and set up the first available appointment. All this is possible because, in general, the providers don’t have to have specific preapproval for treatment from your health insurance. They just need to confirm that you have coverage and that their facility is in network. (Some procedures do require pre-certification.) 

But when you are trying to get that same treatment for a work-related injury, the process is quite different and that is why it doesn’t happen as quickly as we expect it to. When your doctor recommends treatment for a work injury such as an MRI or physical therapy, the doctor’s office has to first submit the doctor’s full dictation note, along with a prescription for the treatment, to the insurance adjuster. Then the provider where the treatment will be done has to contact the adjuster requesting preapproval for the services. Most providers will not agree to schedule the treatment until written approval is obtained from work comp. This causes a delay as it may take a couple days for the doctor’s dictation report to become available and sometimes the adjuster is out of the office or not immediately responsive to the provider. This is why it is important to have an attorney representing you. As soon as you know what treatment is being recommended, the great staff at Black & Jones will contact the insurance company and start pushing them to approve the treatment. If they don’t respond, then we can file a request for hearing before the Commission to force them to respond. 

Unfortunately, our legislature added another mechanism which may cause approvals for treatment to be delayed. Pursuant to Section 8.7 of the Act, now the insurance company can have the recommended treatment submitted for a “Utilization Review”. This is a process by which the treatment records are submitted to a doctor of similar certification as your doctor who then reviews the proposal and renders an opinion as to whether the treatment is medically reasonable and necessary. A utilization review cannot be done regarding emergency treatment. For all other treatment, the utilization review must be completed in a reasonable amount of time. This can sometimes mean several days depending on when your doctor’s office gets all the required information to the reviewing physician. 

If the treatment is then denied based on the utilization review, it is important to have an attorney that can determine why the treatment was not certified and plan a way to prove that the determination was wrong. The attorneys at Black & Jones have dealt with thousands of utilization reviews over the years and know what is necessary to appeal and refute those determinations. So if your treatment is not approved in a reasonable amount of time or is denied following a utilization review, call Black & Jones Attorneys at Law so we can fight to get you the treatment you need so you can get back to living your life in a healthy way.