You have an accident at work. You are seriously injured. You are rushed to the hospital by ambulance. You are treated at the emergency room. Everyone checks on you to make sure you are OK. An insurance adjuster calls you and tells you they are there for you and will help you get to the right doctors. Fortunately, you are able to be discharged. You go home, in pain, with an “off work” note and instructions to follow up with an orthopedic surgeon.
Now, that you are home, the adjuster contacts you and tells you to go to a walk-in clinic/urgent care center. She tells you which one to go to and is very clear that is the only one that is authorized to see you. You go to the Urgent Care the following day. You are seen by a nurse practitioner who recommends physical therapy and releases you back to work “light duty”.
Where is the orthopedic surgeon you were supposed to see? The adjuster tells you that the clinic specializes in “occupational medicine.” You have no idea what that means, but you go to Physical Therapy and try to get back to work.
This is how it often begins. Diverting you to clinics that over which they have tremendous influence. And the fun has only just begun. Once you get referred to a specialist, you are already on the Delay Train. This is a train that stops for inspection every time a doctor makes a treatment recommendation because all treatment in a Florida Workers’ Compensation claim must be pre-authorized by your insurance adjuster. The longer you are in the system, the more stops you’ll make, and the longer some of those stops will be.
How treatment authorization actually works behind the scenes
When an insurance adjuster gets notified of your claim, the first thing many of them think is: how can I close this file? They are all under immense pressure to do two things: 1) keep the cost of claims down, and 2) close files. They don’t do either of those when they authorize medical care.
Insurance carriers are technically supposed to authorize the care recommended by your authorized treating physician as long as it is reasonable, related to your industrial accident and medically necessary. There is a form that your physician is required to fill out at each visit called a Form DWC-25 (DWC stands for Division of Workers’ Compensation). This form answers those questions, and should be all the adjuster needs to authorize the care. If only….
In reality, the more costly or invasive the care, the more scrutiny an adjuster will give. Bear in mind, the vast majority of adjuster have little medical training, if any at all, and I have never seen an adjuster who went to medical school, yet the authorization of your physician’s recommended treatment is in their hands. Can they simply deny it? The answer is: yes, they can. Even without talking to a doctor? Again: yes, they can.
Common delay tactics carriers use
Radio Silence: Failure to Timely Authorize Care. Often times they will not deny the care outright, they will simply not authorize it, which is tantamount to a denial. They drag their feet. They don’t respond to your doctor’s request for authorization. They don’t return your calls. They just do nothing.
Peer Review. They may send it to a physician to do a “peer review”, which is where another physician, often not even in the same specialty, will give an opinion as to whether or not the care is reasonable and medically necessary. They will use this to deny the care if they can.
Utilization Review. Other times, they will tell you that the request or the treatment has been sent to Utilization Review. This happens when they think a physician is overtreating you. This is done less today, because the law allows carriers to select your treating physician, and they rarely select physicians who will recommend a lot of care. Most of the physicians they authorize are
Prescriptions Delayed. One of the biggest things that carriers do to save money is delay authorization of medications. What happens? You show up at the pharmacy waiting to pick up your prescription only to be told the adjuster hasn’t authorized it. Why do they do this? Sometimes it’s an oversight. Other times is incompetence. My cynical take: every day they don’t pay for a medication is a day they never have to pay for that medication. Do that across 1,000 claims and you can save a lot of money.
How to get treatment moving faster
Call the EAO. If you don’t have an attorney (you should probably get one), you can call the State of Florida’s Employee Assistance and Ombudsman Office. Their purpose is to help resolve disputes between employees (injured workers) and insurance carriers. The EAO was once a very helpful agency. Unfortunately, over the past two decades, their funding has been cut and they have little, if any, teeth. The adjuster can essentially ignore them with impunity.
File a Complaint with the Florida Division of Financial Services. While this won’t really help you or change anything, it will probably get under your adjuster’s skin.
File a Petition for Benefits. There is only true way to pressure your adjuster to make a decision and authorize treatment. You must file a Petition for Benefits. Filing a petition for benefits starts the only clock that will really penalize them: attorney’s fees. If they do not authorize the benefit within 30 days of filing a petition seeking the care, they will have to pay your attorney a fee. Do they have to pay you anything? Not for delayed medical care. So, the only hammer you have is an attorney who can make them authorize your care and pay an attorney’s fee.
When delay becomes a violation of the law
Insurance carriers are afforded “a reasonable time” to authorize care, which is fairly vague and case specific. The law requires an adjuster to “respond” within three (3) business days of a written request for authorization of medical care. That response can be a denial, an approval or a request for more information, but a total failure to respond means that the insurance carrier “consents” to the medical necessity of the treatment and care, which can be a great tool during litigation should they deny the care later.
When to stop waiting and bring in a lawyer
The absolute best way to press the carrier for authorization of medical care is to have a lawyer file a petition for benefits. So, at what point do you need a lawyer? If you wait until benefits are being denied or delayed, then you have waited too long. It will take longer to get things moving. You don’t want to be looking for a lawyer while you are waiting on authorization. You want a lawyer to be the one requesting the authorization from the outset, so if the adjuster misses their 3-day window, your lawyer can pounce on it. The bottom line: having a lawyer in your corner before you have a problem with delayed authorization of medical will save you days and often weeks in getting that care authorized. The moment you realize you aren’t just going to get better quickly is the moment you should retain an experienced workers’ compensation lawyer because the chances of you running into a delay of authorization are extremely high.
