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Why is the insurance company denying medical treatment for my workplace injury?

Why can’t I get the medical treatment I need?  This is a question that I frequently hear from many frustrated people.  In the workers’ compensation world, the medical treatment that your employer is required to provide is limited by the Medical Treatment Utilization Schedule (MTUS).  The schedule was sold as a way to streamline access to medical treatment with promises of evidence-based, peer-reviewed nationally recognized standards of care.  On its face, it sounds exactly like something you would want applied to you.  In practice, it makes getting the medical treatment you need more difficult.  I like to think of it like a marketing tool from a cable company where you can get speeds up to a certain limit but everyone knows you’re not getting those speeds regularly.

How do I get treatment in the workers’ compensation system?

insurance company denied treatment workers compensationThe way medical treatment works in the workers’ compensation system is you see your primary treating physician (PTP) who diagnoses your condition and decides on a course of treatment.  But, just because your doctor determines that you need a treatment does not mean that you get that treatment.  Your Doctor must submit a request for authorization (RFA) to the adjuster handling your case.  The adjuster can, but rarely does approve treatment.  Typically, the adjuster submits the request for authorization to Utilization Review or UR.

What is Utilization Review?

What that means is a doctor who you never see and who never examines you reads the RFA and a portion of your medical file and decides whether that treatment is necessary.  If the UR doctor approves your treatment you get it; if he doesn’t you don’t get that treatment.  If your treatment is denied at UR, you can appeal the denial through the Independant Medical Review process or IMR.  In IMR, a second doctor you never see reviews the RFA, the UR denial and your file and either upholds or overrules the UR denial.  If IMR upholds the denial, you don’t get that treatment.  To top it off, you must wait another year before your doctor can resubmit the request unless your condition materially changes.

If that process sounds crazy to you, it’s because it is crazy.  It’s also an excellent way to save insurance companies money.  The hoops that an injured worker has to jump through to get medical treatment under the Workers’ Compensation system lead many people sell back their right to medical treatment at the end of their case through a compromise and release.  (NOTE: Compromise and Release will be a future blog topic) Time and time again I hear clients talk about their frustration with the medical treatment and many express the desire to get out of the workers’ compensation system for good and (hopefully) never have to think about it again.

If you have questions about medical treatment under workers’ compensation, please contact one of our workers’ compensation attorneys.