Gilbert Fisher: When medical treatment has been denied, we first have to kind of assess the situation and try to find out what that means. A lot of times people will come to us because a treatment has been denied, maybe even a prospective client. Sometimes when they say it's been denied, it really has just been ignored, and that might mean that the doctor made the request on the wrong form and the insurance company is simply ignoring it. It's not a denial, it's simply them treating as the request never having occurred. And so, in a situation like that, what we do is we try to track down the source, and if it's not done properly, we then try to contact the doctor and say, "Doctor, can you redo the request? Please use this form, and please make sure you attach the report." And we correct that, and sometimes that's all it takes.
Other times, if there's been a specific denial, the doctor did everything right, and there is a written denial within five business days, then the only thing we can do is appeal that to the Independent Medical Review. And we do that, we've got 30 days to do that, we do that. There can be other reasons too, but obviously we have to look and see what the denial means. Was it a real denial? Was it an untimely denial? If it's an untimely denial, then we can actually file for a court hearing and go before a judge, and give the judge medical evidence for the necessity of the treatment, and oftentimes prevail. But obviously, the first step, when something is denied, is to try and figure out what that means.
There are time limits to everything spelled out in the law. So, for example, if a doctor makes a proper request on a DWC form or FA, the law says that the insurance company has five business days to respond to that, okay. And if they don't do that, then we can actually file for a hearing and go before a judge to try and get the treatment authorized. On the other hand, if they have denied it within those five business days, then we have a timeline of 30 days from that denial to appeal it to the Independent Medical Review Board.
So time is always of the essence. First off, we have to look at the time limits to try and apply those against the insurance company when applicable. And then secondly, if they've done it right, then we have to act quickly to file the appeal.
Narrator: If you or a loved one need help with a workers' compensation issue, call our office today.