FAILURE TO PAY FOR APPROVED TREATMENT

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FAILURE TO PAY FOR APPROVED TREATMENT

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If you are injured or having a work-related injury, then your priority is always the medical treatment at the right time. What will you do if your employer denies you for compensation? Or the insurance company has denied paying for your treatment. Failure to pay for Approved Treatment can be due to many reasons.

Suppose you have taken all the necessary steps like reporting the issue to the employer, filing the correct worker’s compensation form, seeking treatment from the employer and employee approved physician, and he/ she declares you sick and prescribes you a full course of treatment, medication, therapy, complicated surgery, MRI, CT scans, or other procedures. Still, the insurer denies injury treatment.

For all these types of Work-related injuries that are denied by the employer for compensation, read the full blog.

How has the system changed?

Under the current Worker’s Compensation system of California, your doctor’s recommendation first has to be approved by the employer or the insurance company to avail of the compensation.

Here, first, your doctor has to send a form to your insurer requesting authorization. The insurance company then sends the request to the reviewing physician, who can be anywhere in the country. The reviewer then compares the proposed medical treatment with California’s mandated treatment guidelines to make the right decision.

In this whole process, you will not even know the name of the third party examiner.

A doctor acts as a neutral third party examiner who has to conduct a thorough review to come to a correct and reasoned conclusion. If still, you receive an unfavorable response, then you can raise a claim for your rights and you need a work-related injury attorney who will fight for you.

You can, however, challenge the decision with the help of Independent Medical Review (IMR). It sounds quite similar to the independent medical examiner; you can quickly determine from its name only. Independent Medical Review is comprehensive and least personal; it has very significant shortcomings.

Anonymous Decision Making

Here, the physician is not your present treating doctor, who treated and examined you when it comes to the case. An Anonymous physician who ultimately will decide whether you need treatment or not. The state usually has a contract called Maximus, to review the records.

The physician should come to a decision based on health reports. This doesn’t include any internal examination, and there is no question for hearing except for some limited trails. Usually, the IMR decisions are final. So, it can be said that your treatment right’s is made by a stranger, who is anonymous or whose name you can never know.

Delay in the IMR process

This method was introduced, to fasten the treatment access to injured people. On the other hand, it came into the light to improve the cumbersome, sometimes slow and costly judicial process. However, this process fails in both.

IMR process has many delays. When California’s Labour Law came to know about it, it imposed a 30-day deadline for IMR processing as the system didn’t want to take up so vast numbers of cases. As a result, the decisions taken by IMR used to take a minimum of 90 days; sometimes, it can take 120 days also.

According to records, in the first year of the model, it received 73,000 cases, it issued only 3,723 decision and overturned only 16 percent of the cases.

The serious work-related injury requires prompt diagnosis and very swift action taken by a work-related injury attorney. The longer the time is, to provide a detailed report about the treatment to the court, the more significant the harm is.

How can these be removed from the system?

With this IMR process, usually, the injured is stuck at a point which has no meaning, because he/ she can’t have treatment or even can’t be able to return to work. So how this broke off system can be fixed?

Well, there are two ways or elements that need an overhaul: One is Utilization Review, the other one is improved IMR processing.

Improved Utilization Review

The Utilization Review should have more checks and balances. This should allow the injured workers the right to seek a second opinion when their tested doctor’s reports and treatment procedures are denied.

Presently, the system, the treating doctor often gets overruled by the insured’s outstate of the reviewer- who has not even seen the patient. However, providing the patient’s a second option behaves as a fair play. If both the doctors suggest a similar treatment, then the treating doctor’s opinion is not swept aside hastily.

This will save time for the treatment of the injured person as well as, the IMR process will observe a lesser workflow that fastens the process.

Improving this kind of process will cut costs for the insurer in many ways. If the denied treatment, goes through the Utilization review followed by Independent Medical Review, the cost of the insurer will subsequently increase by $1000, and the chances are high that the insurer is fighting for a treatment which costs much less than increased charge. Usually, insurers pass this increased cost to the employer as an Increased Premium.

In the end, the reviewer must be a medical specialist from California. The process can be delayed sometimes, and even we can expect high accountability, and the reviewer would abide by the standard disciplinary rules as of California based treating medical professionals.

Improved IMR process

Reconsideration and improvement of the IMR process is a must so that it becomes feasible for the injured to avail treatment on time.

The prior process involved an independent medical examiner. Who, examine the injured person talks to him/ her face to face, and then report about the work-related injury in a fairway. The process was very neutral; the examiner here acted as a third-party arbitrator.

Now the courts don’t have any jurisdiction to address the Utilization Reviews decision and have the least possibility to overturn Independent Medical Review (IMR) decision. As a result of which a lot of injured workers are denied from their rights to access treatment.

Conclusion

The State of California has a clear picture of how to deal with Workers’ compensation. The current system may fall short in some aspects, but it keeps on updating on a regular basis for the benefits of the Workers and their benefits.

You may have waited too long for what you want, or you have not got what you deserve to get.

Changes are always welcomed and are updating the system. Well, in a similar way, a great attorney who fights for your rights is essential, as he/ she will fight for you in court.

At PSLaw, we help you in these types of issues, and our sole motto is to provide you justice, the best treatment possible for your work-related injury, and you get the compensation that you deserve.

We work for you from the day you come to talk to us and be with you to get the required benefits. If you are thinking, it is so difficult to move to another city to talk to a Lawyer, then don’t worry! Because we are present in all Prime cities in California, such as Riverside, Corona, Hemet, Temecula, Moreno Valley, San Bernardino, Palm Springs. You just have to visit the nearest PSlaw firm.

Feel free to call or email us your query we will revert immediately!

Serving California

The Law Offices of Dr. Peter M. Schaeffer serves the State of California and the Riverside and San Bernadino counties, which includes the surrounding communities of Riverside, Corona, Moreno Valley, Hemet, Temecula, and Palm Springs. Our office locations are conveniently located in the cities of Riverside (main office), Temecula, and Palm Springs

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