A common question that comes up is ‘How does workers compensation medical pre-approval work?’

Very often, especially with diagnostic studies but sometimes with regular doctors offices, the providers want pre-approval, or guarantee from the insurance company that they’re going to be paid, before the provide treatment. Pennsylvania’s Workers Compensation Act does not require pre-approval. Let me say that again. The Pennsylvania Workers Compensation Act does not require pre-approval of medical treatment.

So, when a provider calls the insurance company and asks for pre-approval, the insurance company is not obligated to give it. The insurance company is obligated to indicated whether it is an open, payable claim, or not. And that’s it.

Then it falls back on the provider to decide whther they want to go ahead and give the treatment or study anyway. Generally, the doctors that are familiar with the Workers Compensation system know that there is no pre-approval in Pennsylvania. They know that if the treatment is reasonable, necessary, and related to the work injury it will be paid as long as it’s billed properly, so they’ll proceed with the care.

But we do run into situations where some doctors will refuse to treat people, and there is very little we can do about it. We will talk to the office manager, we will talk to the doctor if they’ll talk to us. Sometimes we can change their mind, but most often if they have a policy, it’s firm, and without pre-approval they won’t treat.

There is one other process that allows us to file for pre-approval. It’s the utilization review process, but that takes several months. So to get something pre-approved through utilization review puts a delay in the treatment of three to four months.

So if you can’t get pre-approval for workers compensation medical treatment, what do you do?

That varies by case and by type of treatment. Sometimes you find a new provider. For example, if it’s a lumbar MRI and you need to get it done quickly to figure out what’s wrong, if one facility won’t do it, we’ll refer you to a different facility. We’ll try to find a facility that will proceed with the MRI even though they’re not getting pre-approval.

Sometimes we’re able to convince the medical provider to go ahead, and sometimes there is only one provider that gives the treatment you’re looking for. There are some specific injections or procedures that are done by only a few people, and in those cases, your alternative is really only to wait until we can get through the utilization review process. So it varies by case.

When is workers compensation medical treatment pre-approval most often sought by a medical provider?

I would say it’s most often sought in situations where there is going to be surgery or diagnostic studies. Office visits are usually not a problem, but if you need an MRI or a CT scan, a lot of those providers will seek pre-approval or pre-authorization. If you’re going to have surgery, it’s common for the hospitals and anesthesiologists to want pre-certification and pre-approval before their treatment. So diagnostic studies can be difficult to obtain without pre-approval.

We often are able to overcome that by using people’s private health insurance as a backup. So what happens there, is that we tell the provider to bill workers’ compensation and if workers’ compensation were to deny the claim, the private health insurance would have to pay it. That encourages the provider to go ahead and provide the treatment by getting pre-approval or pre-certification from the private health insurance, even though they’re not intending to bill their private health insurance without a denial from workers’ compensation. So that is another work-around.

The advice offered above is general in nature and may not be applicable to every case. Consultation with an attorney is highly recommended. Reliance on this advice does not represent the formation of an attorney-client relationship in the absence of a fee agreement with Mr. Hillsberg.

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