EUnderstanding why your treatment is denied by your employer or carrier can help you navigate the workers' compensation system more effectively. Employers have the right to contest the payment of both indemnity and medical benefits for various reasons.
Common Reasons for Treatment Denial
- Incomplete Paperwork: Insufficient documentation can lead to denial.
- Inappropriate Treatment: Treatments not deemed appropriate for the injury may be contested.
- Unapproved Doctor: If the doctor is not approved by your employer or insurer, this could result in denial.
Utilization Review (UR) and Its Impact
In some states, a process known as Utilization Review (UR) allows employers or insurance carriers to assess and possibly remove certain medications or treatments from your plan. If your treatment doesn't align with a UR recommendation, it might be contested.
What to Do If Your Treatment Is Contested
When treatment is challenged, your employer typically must notify your state's workers' compensation agency and explain the reason for denial. As an injured worker, you can contest this denial through formal state procedures and argue why the treatment should be approved.
Post-Settlement Treatment and Medicare Set Asides
If your claim is settled and includes funds earmarked for future medical treatment, these decisions are generally between you and your physician. However, if a Medicare Set Aside (MSA) is involved, you must ensure that expenses paid by the MSA are related to your initial injury and are covered by Medicare, as per the Centers for Medicare and Medicaid Services’ (CMS) guidelines.
For detailed information on contesting treatment denial, you may want to consult your state's workers’ compensation agency or a legal professional.
