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Treatment Authorizations in Workers' Comp: 5 Easy Steps to Deal with Them

Woman pharmacist with colleague talking at a pharmacy

Waiting for your treatment authorization can be so frustrating. When you get injured, you don’t want any delays in your treatment. This feeling is understandable, as you are in pain, scared, and eager to return to your job soon.   

This matter is one of the most essential and significant in Workers’ Compensation cases. Sadly, it is also a quite common subject in this legal system. One that cannot be avoided. But after you read this article, you’ll understand this process way better. This new knowledge will give you an advantage when it is your turn to deal with it. 

So, if you are currently in a claim process involving any treatment, chances are you are dealing with authorization issues. How can you get through this journey in the easiest way? Find valuable information to help you do so in the following paragraphs. 

Summary 

1. Learn What Treatment Authorization Is About 

2. Wait for the Authorization 

3. Pay Out of Pocket if You Cannot Wait 

4. Contact the Adjuster if You Can’t Get Your Medicine 

5. Go for an IMR if Your Treatment Is Denied 

1. Learn What Treatment Authorization Is About 

In the Workers’ Compensation legal system, you will find something called Utilization Review (UR). It is a mechanism in which the insurance company gives the treatment authorization a review. 

In other words, they inspect all the details in each prescribed treatment.  

After this inspection, the insurance company can either authorize or deny the treatment that the doctor requested, based on the review results. 

This Utilization Review applies to a variety of matters, such as: 

  • Surgeries 
  • MRIs  
  • EMG studies  
  • Physical Therapy 
  • Medication  

So, when your doctor gives you a prescription, it must be authorized by the insurance company for you to claim it. But the bad news is that the insurer might deny it.

They can also authorize part of it, which means the pharmacy can only fill part of the prescription. 

For example, if your doctor prescribes 30 units of any pill, the insurance company may only authorize 15 units. That is, they may modify it to be partial rather than a full one.  

If this is happening to you, and you feel this result is unfair, don’t give it a second thought: Get an attorney.  

2. Wait for the Authorization 

After your injury, waiting for authorization will look like an eternity. Sometimes you need your treatment as soon as possible. Some diseases must be treated quickly, such as heart disease, diabetes, high blood pressure, or any similar condition. 

In this decisive situation, we advise you not to wait for authorization. We know that it can be quite frightening to pay for it yourself, but your wellness cannot wait for the insurance company.   

So, if you do have to pay out of pocket, do it. Don't be afraid. In most cases, you will get your money back. Your health is the most critical aspect to consider, so do what is best for your well-being. 

3. Pay Out of Pocket if You Cannot Wait 

Let’s say you have your medication authorized. Yet, the pharmacy has not received the authorization for whatever reason, and you end up paying it out of pocket. Don't worry! You are entitled to reimbursement.   

The best way to approach it is to negotiate with the adjuster and try to remedy the situation through dialogue with them. However, if the insurance company doesn't help you, you need to request reimbursement by going to court.  

Whenever your treatment authorization wasn’t issued, or your pharmacy was not authorized in time, and there are no valid reasons for it, you are entitled to request penalties and sanctions

4. Contact the Adjuster if You Can’t Get Your Medicine 

Now you have your prescription authorized. Great! So, the next step is easy: Go to the pharmacy with your prescription and pick your medication up. 

But you can meet another issue: getting the pharmacy to fill it. It happens from time to time that medication gets authorized, but the decision is not communicated to the pharmacy on time, which causes an unpleasant delay.  

If this happens to you, you have these options to solve it:  

  1. Talk to your insurance adjuster and ask for a quick resolution. If the adjuster is not available, ask for the supervisor.  

  1. Assuming that you cannot find help from the adjusters and need the medication straight away, you can pay it out of pocket.  

This last option sounds scary, considering that medications are expensive. Besides, you can also be afraid you will not get the treatment authorized to pay that money back. Yet, that is not usually the case. An experienced Workers’ Comp lawyer will answer all your questions.  

5. Go for an IMR if Your Treatment Is Denied 

The insurance company may deny your treatment or prescription. However, not everything is lost. In this case, you can go through an Independent Medical Review (IMR).  

To put it differently, you can appeal the decision of the insurance company —the authorization denial— whether it was a partial denial or a complete one.  

The IMR will study the case and give a verdict about your treatment or prescription. If you receive a denial for the medication from them, then your treatment will not be authorized. It means you will not get the medicine you need.  

It is also possible that they authorize the treatment partially, so in this case, you will only get the recognized amount. In such situations, to have a lawyer alongside you is the cleverest decision you can make. 

Summing Up 

You can find plenty of different scenarios and outcomes related to treatment authorizations. You can get one straight away, you may have to wait for it, or you might even need to go to court to get it.  

What is expected in all cases is that you need to act promptly. Don't wait around for the result. Be proactive. Get an attorney who helps you carry this burden.  

But if you prefer not to, talk to the claims adjuster or their boss, or go straight to the WCAB and look for information and assistance.   

Don't rest on your laurels. It is fundamental that, if you need medication, you do all you can to get it fast. Your treatment is the top priority in your case. An attorney will ease your experience through this journey, so you can focus on regaining your health. 

Reach us for free at 800-606-6999 or make an appointment.    

Pacific Workers', The Lawyers for Injured Workers in Northern California's Premier Workers' Compensation Law Firm. Representing First Responders, Health Care Workers, Construction Workers, Delivery Workers, Warehouse Workers, and all the hard-working people that keep our community moving in their Fight for Justice against the Insurance Companies.     

With over 250+ Five Star Reviews; an incredible staff of caring, well-trained, advanced technology for superior client communication: a track record of an over 98%-win rate, and giving back to our community through the Pacific Workers' Foundation, it is easy to see why Pacific Workers' is the go-to law firm for all injured workers in Northern California. Offices in Oakland, Concord, Stockton, Tracy, San Jose, and Sacramento.     

If you or a loved one need help or just have a question, give us a call at 800-606-6999 or email us at Intakes@pacificworkers.com.     

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