What To Do When Faced With A Denial Of Treatment Related To A Workers’ Compensation Benefits Claim
If an employee is injured on the job, a doctor will prescribe a certain course of treatment after conducting a medical evaluation. This may include any combination of prescription or over-the-counter medications, therapy, surgery, and other treatments. After determining the appropriate course of treatment, the doctor will send a Request For Authorization (RFA) to the employer’s insurance carrier. The insurance carrier’s utilization review department then considers whether to approve or deny the RFA. The utilization review department is supposed to rely on certain guidelines, including a Medical Treatment Utilization Schedule (MTUS) in arriving at an approval or denial decision. If the utilization review process yields a determination that the doctor’s request does not fit within the MTUS guidelines, a denial letter will be sent to both the employee and the employee’s doctor. Reasoning may include an outright rejection of the proposed treatment, or a need to try other treatments before moving forward with the proposed treatment.
Appealing the Denial of Treatment Decision
It is possible to appeal a utilization review department’s denial of a doctor’s RFA. One method is for the employee’s doctor to send in a doctor’s appeal. Here, after reviewing the denial letter, the doctor sends in a response letter stating his or her disagreement with the denial, and restating the reasons why the originally proposed course of treatment is, in fact, necessary. Basically, in a doctor’s appeal, the doctor is asking the insurance carrier to reconsider the original request. Also, the doctor might include additional documentation in the appeal submission, or include reference to other attempted treatments that may not have been detailed in the original RFA.
Independent Medical Review of the Denial of Treatment
As of January 2013, there is a second process of appeal available to injured employees facing a denial of treatment from an employer’s insurance carrier. This process is called Independent Medical Review (IMR), and it relies on the reasoning of a qualified and neutral third party. Presently, if a utilization review results in a denial of an RFA, when sending the denial letter, the insurance carrier must include an IMR request form for the employee to fill out and submit if he or she wishes to appeal the denial. The IMR is conducted by a doctor who works for the state of California in a division of the Department of Workers’ Compensation, rather than the insurance carrier. The IMR doctor reviews the original letter from the injured employee’s doctor, and determines whether or not it should have been approved. If the IMR doctor determines that the original RFA should have been approved, the insurance carrier must approve it.
Have you been injured on the job in the state of California? Is your employer’s insurance carrier attempting to deny your doctor’s requests for treatments? You are not without rights during this stressful time. For assistance with your workers’ compensation claim, contact an experienced California workers’ compensation attorney. An attorney will explain your legal rights, and fight to obtain the maximum benefits you may be entitled to.