Understanding Delays in Medical Care in Worker’s Compensation

Dealing with a worker’s comp claim is never easy, and that frustration can increase drastically if you are also forced to accommodate delays in receiving medical care. While it’s perfectly understandable that you are irritated, frustrated, and just want the situation taken care of, it also helps to make sure you understand your rights, as well as what the adjuster is required to do in your case.

Doctor’s Request Approvals/Denials

While you are covered for treatment of your work related injuries, some treatments and procedures will require authorization from the worker’s compensation adjuster before you can begin or undergo them. These include:

• Diagnostic imaging
• Consultations
• Non-emergency surgery
• All elective procedures
• Six or more physical therapy visits
• Any services that are estimated to cost $200 or more

In Las Vegas, worker’s comp adjusters have up to 30 days after receiving your claim to approve or deny it. However, they have only five days for doctor requests. You will still be able to seek appropriate emergency care and attend scheduled clinic visits, but you won’t be able to begin the doctor’s recommendations until they are approved. You should also expect the adjuster to schedule a consultation for a second opinion or review after receiving a doctor’s request – this is a common practice that is used to help provide better control over worker’s comp claims.

Potential Causes for Delay

While your frustration level may grow daily, you need to make sure you understand exactly what is causing the delay. Your first step should be to contact the doctor’s office to verify when the authorization request was faxed to the adjuster. If the procedure that the doctor requests has a considerable cost associated with it, your doctor will also be required to fax a dictated report, and answer any potential questions the adjuster may have.

If you have verified that the doctor sent the information, your next step is to contact the adjuster to make sure the information was received. As faxes are notoriously misplaced, you may find that the appropriate person did not receive it – if not, request that your doctor resend the information.

Your Responsibilities

You also have certain responsibilities when it comes to Las Vegas worker’s compensation treatment requests. The first is that you comply with the adjuster’s request for an additional consultation, as failing to do so could terminate your benefits. Secondly, understand that repeated calls within a single day, or resorting to abusive language when speaking with the adjuster will result in delays. Additionally, if you notice that the adjuster is requesting multiple doctor’s visits for second opinions, you should probably consider finding an attorney – this typically is a red flag that the treatment request is going to be denied.

Denials or Lengthy Delays

If the adjuster denies your treatment request, or there are exceptionally long delays, you will need to request a hearing and contact the DIR with your complaint, making sure to send a copy to your adjuster as well. This will typically prompt the adjuster to respond to the request.

Bighorn Staff

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