What can you do if your treating doctor wants to refer you to a specialist, or tries to order an MRI or CT scan, but the workers’ compensation insurance company refuses to authorize this needed treatment?
Under Georgia workers’ compensation law, if you are receiving care from a “authorized treating physician” and that authorized physician refers you to a specialist, the referred doctor is supposed to be authorized automatically.
Similarly, if an authorized treating physician writes an order for an MRI, CT or other diagnostic test, that test should also be authorized.
What we are finding, however, is that when the referred doctor or the medical testing center calls the insurance company to verify that they will be paid, the insurance adjustor may say “no.” And of course, if a medical provider or testing center does not have a source of payment, they will not provide treatment to you.
Why do Insurance Companies Play Games with Your Medical Care and What Can You Do About It?
Often times there is no valid reason for the insurance adjuster’s refusal to authorize treatment. The adjuster knows that a workers’ compensation judge will rule against the insurance company but they also know that it will take us 3 to 6 months to get a court date. In the meantime, they can try to convince us (you and your attorney) to agree to a doctor on their list, or perhaps they can try to negotiate a lowball settlement.
My response to this type of unreasonable medical care authorization denial is simple – I will call the adjuster once in a good faith effort to get my client’s reasonable and necessary medical care authorized, and if that effort is not successful, I will request a hearing and ask for attorneys’ fees and penalties for the unreasonable denial.
Once a hearing is requested the insurance company file will be sent to an insurance defense lawyer who will hopefully advise his client to do what the law requires. Sometimes it takes a phone call or two to the adjuster or the defense attorney for me to demonstrate that I know how the system works and that I do not intend to let the employer/insurer dictate the progress of my client’s case.
In any case, I will not agree to an untrustworthy doctor, nor will I recommend settlement to my client unless and until we have enough medical and other information to know that the time is right for settlement.
Use State Board Form WC-205 to Speed Up Authorization
Another option we have to speed up the process is to use a procedure set forth at State Board of Workers’ Compensation Rule 205. State Board form WC-205 is a form published by the State Board that allows a treating doctor to ask for authorization or testing. If your doctor fills out this form and we submit it to the insurance company, the insurance company then has 5 days to set forth a specific reason why the requested treatment or testing should not be authorized.
If the insurance company does not respond within 5 days, the authorization will be automatically approved. This WC-205 process can be a very powerful tool and I have used it many times for the benefit of my clients.
Posted panel doctors who get most of their business from insurance companies may be less inclined to cooperate and complete a WC-205 but other, more independent doctors will often help their patients by filling out this form.
Given the importance of timely medical care for my clients, I usually have very little patience with any insurance adjuster who appears to be intentionally delaying medicare care authorization. My goal in all cases, of course, is to help my client get quality medical care quickly and to advise my client about how to maximize all benefits provided under Georgia law.