Medical Care and Utilization Review

When your doctor orders medical treatment for your work related injury or illness, the Workers’ Compensation insurance company is required to follow a set of Utilization Review Procedures outlined in the Louisiana Administrative Code to decide whether to approve or deny coverage for the treatment. In fact, there are two sets of procedures. One covers requests for surgery and inpatient hospitalizations, while another covers other types of medical treatment, such as physical therapy, prescription medication, or medical tests (MRI, EMG, CT Scans, etc.).

If the medical treatment includes an overnight hospitalization or surgery, your doctor should fax the Workers Compensation insurance company the basic information about the type of treatment you need and the insurer should then contact the doctor’s office to request the specific information they need to review the treatment request. If the treatment includes surgery, the insurance company may schedule an examination with a different doctor for a second surgical opinion. If the insurance company doctor disagrees with the claimant’s treating doctor, then the claimant or the insurance company may request an Independent Medical Examination with a doctor appointed by the Office of Workers’ Compensation or a Workers’ Compensation Judge.

When all of the information is available, the Workers Compensation insurance company must indicate whether they will cover the cost of the hospitalization or surgery. If the hospitalization or surgery is denied, you may file a Disputed Claim for Compensation with the Louisiana Office of Workers' Compensation to ask a Judge to determine whether the treatment should be approved.

For other types of medical treatment, including prescription medication, physical therapy, medical devices, medical tests (MRI, EMG, CT Scans, etc.) or other treatment that doesn't require an overnight hospital stay, the doctors should send the insurance company a report that contains the following information:

• the patient’s history and physical examination results, including a clinical summary.
• the diagnosis.
• the type of service or treatment the doctor is requesting.
• the plan of care, including the expected length and frequency of treatment.
• the patient’s prognosis, including the expected outcome of the treatment or test.
• any test results and interpretations that support medical necessity of the treatment requested.
  

In practice, the doctor’s office will often call the insurer to set up the test or treatment and the insurance company will then let the doctor know the type of information they need in order to review the request. The doctor’s office should then fax the information as soon as possible.

A nurse working for the Workers’ Compensation insurance company should review the request and approve or deny coverage for the treatment within seven calendar days of the date of that the doctor’s office provided the required information. If the Workers’ Compensation insurance company does not respond within seven days, the claimant may assume the treatment was denied and file a Disputed Claim for Compensation with the Office of Workers’ Compensation. A Workers’ Compensation Judge may then assess penalties against the insurance company for failing to follow the Louisiana Utilization Review Procedures.

If the insurance company’s nurse decides the treatment is not medically necessary, the insurer should have the request reviewed by a doctor of the same medical specialty as the doctor who ordered the test or treatment. If the insurance company doctor agrees that the treatment is not medically necessary, the insurer must notify the treating physician and claimant in writing immediately. The insurer must also fax the information they based their decision upon to the Louisiana Office of Workers’ Compensation Medical Services Division.

The Medical Services Division will review the information and may either:

• Schedule an Independent Medical Examination to obtain additional advice.
• Agree with the insurance company’s decision to deny the treatment.
• Disagree with the insurer and recommend that the treatment be covered.
  

Once the Office of Workers’ Compensation issues its recommendation, either party (the claimant or the insurance company) may file a Disputed Claim for Compensation with the Workers’ Compensation Court. If a Disputed Claim for Compensation is filed with the Louisiana Office of Workers’ Compensation, the dispute can be presented to a Judge for a determination of whether the treatment or test should be approved.

If the Judge decides that the Workers Compensation insurance company failed to review the request within seven days of receiving the information from the doctor’s office, the Judge may impose a penalty. If the Court finds that the insurer or employer “arbitrarily and capriciously” refused to approve the claimant’s medical care, the Court may order an award of attorney fees as an additional penalty. It’s necessary for the claimant to prove that their doctor submitted all of the required information and the insurance company acted irresponsibly in failing to follow the Louisiana Utilization Review Procedures in order for the Court to conclude that the insurer handled the claim in way that was “arbitrary and capricious.”

• David Buie is a Louisiana Workers Compensation Lawyer who represent individuals throughout all of Louisiana. For more information, visit DavidBuie.com