My medical treatment has been denied. Why?
When the insurance administrator denies a physician’s request for reasonable medical care, it is generally done through the Utilization Review (UR) process. UR is used by insurance administrators to determine if medical treatment is necessary, based off their medical treatment guidelines. In other words, an insurance carrier will only provide medical treatment that is proven to cure or relieve an injury.
This can often be a frustrating time for an injured worker. Often a cost-effective treatment is recommended that may not provide all the benefits the injured person deserves. The key to achieving the best benefits is getting past this difficult UR process.
The Law Office of Gerald D. Brody & Associates will designate a treating physician to your claim who will adequately request medical treatment in order for you to pass your UR. If treatment is denied, we will analyze the UR decision along with the doctor’s request and fight to obtain the medical treatment for you, appealing the decision and taking the decision to court, if necessary.
What do I do now?
When UR denies a physician’s request for treatment, the insurance carrier must provide notice to the doctor and to the injured worker that the treatment has been non-certified. The requesting physician must be notified within 24 hours of the determination and notice to an injured worker must be sent out by the claims administrator within 24 hours of the decision.
A UR must also be conducted within five business days of the claims administrator receiving the doctor’s request for treatment. The doctor’s request must be made on a particular form, and proof that the form was either sent out by mail or via fax is required to hold the claims administrator to the 5-day review period.
The bottom line: Utilization Reviews are very seldom done right. If your treatment has been denied by the insurance company, contact our office to speak with a professional attorney about how to dispute a denial letter, and what other options you may have to get the treatment you need to get better and back to work.