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Is your medical treatment or testing being delayed?

One of the biggest problems I see with Massachusetts workers’ compensation cases is the delaying or denial of medical treatment and testing. There are several steps involved in obtaining your medical treatment/testing through workers’ compensation.

Workers’ Compensation Rates

In Massachusetts, workers’ comp insurers are only required to pay set rates for medical treatment/testing services. And the set rates are very low. Many doctors will not accept these rates. Under the law, there is no way to force the insurer to pay more than the set rate. Many insurers will negotiate with a doctor to pay a higher rate. In my experience they only do this if they feel it will benefit them (i.e. paying more for a good doctor will result in better treatment and get the injured worker back to work sooner). But this negotiation process will delay treatment.

This is especially problematic when the injured worker is waiting for a surgical procedure. And doctors usually will not use available health insurance coverage because once the surgery is performed, they lose their negotiation leverage. If the health insurer then withdraws its payment and the workers’ compensation insurer is ordered to pay by a Judge, they will only have to pay at the set rates because the law does not allow the Judge to order payment at more than the set rates.

Utilization Review Process

Under the Massachusetts Workers’ Compensation laws, all treatment (such as surgery or physical therapy) and testing (such as x-rays, MRI’s etc.) have to be approved through the Utilization Review (UR) process. If a medical provider wants a test or treatment to be done on an injured worker patient, they are supposed to submit the request and supporting medical documents to the UR provider that is assigned to the claim. Some workers’ compensation insurers use outside UR companies and some have in house UR departments.

It is important that the medical provider send the request to the UR provider and NOT the workers’ compensation insurance adjuster. Sending the request to the adjuster just delays the approval process. Once the UR provider gets the request, they are supposes to look at it to see if the proposed treatment/testing is appropriate for the type of injury the worker has. The state has set guideline for determining if it is appropriate. At this stage it is usually a nurse at the UR provider making the determination. The treatment/testing is either approved or denied. If it is denied then the medical provider should file for an Expedited Appeal. The request will then have to be reviewed by someone in the same medical specialty as the requesting medical provider. The UR reviewer and the injured worker’s medical provider may discuss the request in a telephone conference. A decision on the request must be made within 48 hours on an Expedited Appeal request. If it is denied a second time, then a claim can be filed with the Department of Industrial Accidents and a Judge will decide if the treatment/testing should be ordered.

Having an experienced workers’ compensation attorney representing you will help cut through the red tape involved in obtaining medical treatment/testing. If you are having problems getting your medical treatment/testing, call me now to schedule a free consultation.

Don’t Wait. Insurers only have 14 days to pay or deny your claim. Learn how to improve your chances of having your claim approved.