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The insurance company won’t approve my treatment. What can I do?

by | Apr 22, 2022 | Workers' Compensation |

Opposite the usual requirement of pre-approval for medical treatment – involving private health insurance, Medicare or Medicaid – there is no pre-approval of treatment under worker’s compensation.

There is also no legal requirement for the claims representative to “communicate” with a treatment provider: only that they not misrepresent the law or the claim status. Ignoring a Provider is one method of avoiding ‘miscommunication’. Any language that is intended to discourage a treatment provider from rendering care may be a violation of the law – but the Provider will (usually) be required to testify, in order to prove the actual context of the discussion. (If the treatment provider will not agree to render treatment, they very likely would not agree to testify. If they do render treatment, the conversation did not “discourage” them. Insurance companies KNOW this, which is why they often do it AND get away with it.)

Unfortunately, if a treatment provider simply does not want to “get involved” with workers’ compensation legal issues and possible litigation, the injured worker can not force the Provider to treat them. The option is to find a Provider who will. This is sometimes difficult with “uncommon” work injuries, such as vision, hearing or heart-related issues.

An aggressive Workers’ Compensation Lawyer will have a number of strategies to enable their clients to get the necessary treatment, ranging from polite discussions with the insurance company or their attorney; to finding competent, willing treatment providers; to filing the proper Petition to obtain confirmation of the claim status and liability to pay for treatment. The best strategy varies from case to case, and among different insurance companies. Experienced Worker’s Compensation SPECIALISTS have dealt with virtually every insurer and scenario, and know what is best in each case.

What should I do if the insurance company won’t pay my medical bills?

The first step is to make sure the medical bills were submitted in accordance with the requirements of the Worker’s Compensation Act.

AFTER treatment is rendered, a Provider must submit their bill on the correct form (an HCFA 1500 form) along with a specific workers’ comp form (an LIBC 9), and the Provider‘s report. Our office can send any of these to a treatment provider, if needed. The report should include the history of the work injury, any other relevant past medical history, exam findings, diagnosis and opinion of causation of the condition treated.

The treatment provider should keep records of the dates and forms submitted, just in case of delays in payment, improper amount of payment, or non-payment. Without proper documentation (evidence), it is difficult for even the best lawyer to win a case.

Within 30 days of receiving the proper billing documents, the insurer must (a) pay the bill at the rate reflected by PA law (not ‘whatever’ the Provider charges) OR file a Request for Utilization Review, challenging whether the treatment is reasonable and necessary.

Our office (generally) agrees to fight any challenges to our client’s treatment – assuming the Provider likewise cooperates in providing us the ‘evidence’ necessary to do so. This usually just requires the treatment and billing records (to PROVE proper submission), but may sometimes require a deposition to authenticate the documents and dates. We also represent many treatment providers directly – where we do not represent the claimant, but would (obviously) seek a fee from any bills recovered.

If the bill is not paid timely, in the correct amount – or not paid at all – there are once again several different options. A skilled lawyer knows which option is best in each unique situation: from polite conversations to seeking penalties, interest and counsel fees.