Worker’s Compensation Claims Reasons for Denial
By: Mary Thompson, Capstone Brokerage President, June 29, 2016
Worker’s Compensation claims are already a headache to deal with. Between completing the correct paperwork in a timely manner to OSHA breathing down your neck; it can be tremendously stressful for employer, employee, and carrier. To make things more difficult, 90% of independent medical reviews done by an independent party in California upheld the modification or denial of medical treatment as unnecessary.
To break this down a bit further, when a worker’s comp claim is processed, the doctor treating the injured employee may suggest a particular course of treatment, such as; physical therapy, cortisone shots, surgery, etc. An employer and / or Worker’s Compensation carrier may look at this treatment and dispute it as medically unnecessary in order to cut down on costs and only give the appropriate amount of treatment to an injured worker. A third party must then be called in to review these medical cases and decide if the course of treatment recommended by the physician is indeed medically necessary for the injured employee. In a study in California, 88.8% of 40,742 independent medical reviews deemed that treatment modifications were in order or upheld the denial of treatment entirely as medically unnecessary.
“This consistently high uphold rates shows that the vast majority of the disputed modifications and denials made by utilization review physicians continue to be in line with the evidence based medicine guidelines,” according the to the California Worker’s Compensation Institute (CWCI).
According to the CWCI, almost half of all the independent medical review cases were regarding prescription drugs within the first quarter of 2016. Not surprising, 9 out of 10 of these prescription drug cases involved opioids. Surgery added up to less than 5% of cases under review. Physical therapy, durable medical equipment, and injections were also very common subjects of disputes submitted for independent medical review. The overall rate for the independent medical review was 90% of all services were not medically necessary.
When your company has an injury on the job site it is imperative to get in contact with your broker and insurance carrier right away to handle the situation properly. Worker’s compensation has time sensitive paperwork. A knowledgeable broker will be able to guide you through the process of a worker’s compensation claim to ensure you are following the legal guidelines to protect yourself and your employee. As an employee it is imperative to indicate that the injury happened while on the job as different forms will be required from the medical professional who provides you care. The Importance of Timely Reporting Workers’ Compensation Claims is critical for all parties.
