Approval for Medical Treatment from Workers Compensation Insurance

If you've been injured on the job in New York and need workers compensation insurance to cover medical treatment, you may need to jump through some hoops to get authorization.

The New York State Workers' Compensation Law does not require approval by an insurance carrier for medical services costing less than $1,000.00.  Unfortunately, most health care providers require authorization from an insurance carrier before providing any medical treatment.  Obviously, they are concerned that they will not be paid for the treatment unless they receive prior authorization.

Where medical services costing in excess of $1,000.00 are recommended, formal authorization from the insurance carrier is required.  This means that the provider requesting approval for the services needs to submit a formal written request for authorization.  This can be done utilizing the Workers' Compensation Board’s C-4 AUTH form.  The insurance carrier has 30 days from the date that form is received by the Workers' Compensation Board to either approve or deny the treatment requested.  It is noteworthy that the 30 day period begins to run, not from the date of the written request but from the date it is actually scanned into the Workers' Compensation Board electronic case file.  That can be weeks or even months after the doctor performs the examination and submits the request.  Nonetheless, the carrier has 30 days from the date the Workers' Compensation Board has received the written request.

In order for the carrier’s denial to be effective, they are required to provide written notice of the denial to the requesting provider, the claimant, and the claimant’s attorney.  They are also required to attach medical evidence specifically indicating that the treatment is not necessary or appropriate.

In most situations, even if the carrier files a timely objection, utilizing form C-8.1, they rarely attach the requisite medical evidence supporting their denial.  As a matter of law, failure to comply with the Workers' Compensation Board’s rules will result in authorization of the requested procedure.

In theory, the rules sound effective.  However, in practice, most insurance carriers will not approve the requested treatment until formally directed by a Law Judge.  A relatively new procedure allows a Workers' Compensation Chair to issue a written order approving medical treatment without a formal hearing. When this happens, the onus is on the medical provider to go forward with the treatment. In practice, providers want approval from the insurance carriers and not the Workers' Compensation Board because it is the carrier that will be paying the bill.

A large part of practicing law in the area of Workers' Compensation involves contacting insurance carriers for the purpose of securing authorization for medical care so that clients can receive the necessary treatment.  In many instances, the insurance carrier will continue to object to the treatment and the hearing process must be resorted to.  That process is still extremely slow and can delay treatment by months at a time.

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