This is part two of a two part discussion on how to get the treatment you need for a Workers’ Compensation injury. In the first part of this series, we discussed the basic roles of the “Primary Treating Physician,” the Utilization Review process, and the Independent Review Process and its challenges. In part two, we will provide some practical tips to help you increase your chances of receiving approval of the treatment you need.
Part 2: The second step in understanding how to fight for the right care is understanding how to avoid the fight altogether.
Selection of your “Primary Treating Physician” to avoid a fight.
When you go out on a special occasion for an “Italian Dinner” do you go for the cheapest Italian food you can find, do you go out for the best Italian food you can find regardless of price, or do you go out for the best Italian food you can find within your budget? Choosing your physician should involve a similar compromise. However, instead of quality and price as the key factors, it should be quality of care and familiarity with how to navigate the Workers’ Compensation system.
For routine medical injuries that are seen by physicians day in and day out, you should take extra care to select a Physician that is well respected within the Workers’ Compensation community. Respect within the community is based not only on the outcome of their treatment, but on their ability to effectively communicate with your Workers’ Compensation attorney and the insurance companies.
There are many extraordinary physicians that simply do not communicate well. Some are simply poor communicators in general, while others may be poor communicators because they do not like their decisions being reviewed by Workers’ Compensation claims adjusters. Regardless of the reason, if you choose one of these poor communicators, you almost certainly will later be faced with a denial of medical care. Too often we see physicians become defensive and emotional about a denial. Unfortunately, this can lead to further problems.
If the Workers’ Compensation insurance company that you are dealing with has a medical provider network (MPN), you must treat within that network. There are exceptions to this general rule. We will explore those exceptions within another discussion.
When interviewing Physicians on the MPN, you should begin by asking the receptionist or intake nurse point blank what percentage of their practice involves Workers’ Compensation. If the number is relatively low compared to other physicians in their practice area, be extremely cautious. This should be considered a red flag. It does not mean that they are not very good, but rather, it means that they may not be well versed in how to document a file to ensure that your needs are approved. Once you are meeting with the physician, do not be afraid to inquire again to make sure the intake nurse was accurate.
In addition to inquiring of the physician and his/her staff, do not be afraid to ask your attorney. A good Workers’ Compensation attorney should have a general understanding of which physicians in the local area are well versed in the Workers’ Compensation system and which are good communicators.
Do Your Own Medical Research!
The internet provides you with a wealth of information. You should never try to treat yourself, and you should always be respectful of the physician who has years of training and experience, but a little background information on various forms of treatment for your injury may help the process. There are various websites such as WebMD that will explain to you various possible treatments, possible alternatives, and possible concerns for a treatment.
If you have researched these issues in advance, you can have a well informed discussion with your physician. This is not only helpful to your physician, but it often serves as a prompt for them to make certain notes in your medical records as to why the chosen course of action is better than other alternatives. What your physician writes in your medical records, or what they forget to write, can single-handedly be the number one reason why treatment is approved or denied.
If your physician simply concludes that an expensive treatment is necessary without a lengthy dialogue about the reasons why, or the reasons why an alternative is not recommended, you can almost guarantee a denial by utilization review, and a denial by the independent medical reviewer. However, a well articulated description of what is needed and why can dramatically increase your approval rate. These chart notes are the primary ways that physicians communicate evidence in support of their decisions and should never be taken lightly.
How to Appeal the Denial by Utilization review
So your request for treatment has been denied, and thus for many the instant response is “how do I appeal?” While appealing to the independent medical reviewer is certainly an option, often the best option is to have your physician carefully review the file and the utilization review denial, and make sure that he/she thoroughly explained why this treatment is best for you, and why the other options are inferior. Many physicians get frustrated at this point, and simply respond that they did note the file appropriately. The best Workers’ Compensation physicians will often supplement their prior request with a more thorough explanation, addressing the reasons for denial provided in the denial of treatment. These are the best Workers’ Compensation physicians, as they know how to work within the system.
If after supplementing the records the utilization reviewer still denies the care, then the timely filing of a Request for Independent Medical Review is best. There are many articles and authors that suggest writing letters to accompany the appeal, but if you followed the steps above, those additional notes may be unnecessary. Hopefully you have selected a well respected physician, worked with them to provide the information needed to properly document your medical records, and they have properly documented those records.
