Workers’ Compensation covers doctor visits, hospital costs, medical testing, chiropractic treatment, physical therapy, prescriptions, medical devices, and other treatment related to your work injury.

Rothermel & Wilson will help you navigate the process of getting your treatment approved. If your treatment is denied, call or email so we can discuss what we can do to expedite the approval process.

Click here for a list of doctors who treat workers’ compensation claimants.  If you would like to discuss which doctors you should see, please call.

Medical Treatment Authorization

You both do and do not need to worry about medical authorization.

First, you do not need to worry about surprise medical bills. If you are provided treatment and it is not properly authorized/pre-authorized, the doctor does not get paid — but they are not allowed to bill you either.

You do need to worry about the workers’ compensation bureaucracy delaying your treatment.

• For treatment consistent with the Workers’ Compensation Medical Treatment Guidelines, your doctor does not need any kind of pre-authorization.
  • If your doctor wants to want to confirm that the treatment is covered:
    • They can file an MG-1 form through the Workers’ Compensation Board’s Medical Portal.
    • Once the provider has submitted an MG–1 form the carrier has eight days to respond.
    • If the carrier denies the treatment, you should ask your doctor to appeal. Attorneys generally cannot appeal MG-1 denials.

• For treatment which is not pre-authorized by the Treatment Guidelines your doctor must file a variance (MG-2) through the Board’s Medical Portal.
  • Carriers typically have 15 days (sometimes 30 days) to respond.
  • You should ask your doctor to appeal any MG-2 denials.
  • Any appeal should be filed within 12 days. If the doctor does not appeal or that appeal is denied, we can file a request for hearing.
• Rothermel & Wilson will help you to navigate the workers’ compensation medical approval process to help you received treatment as quickly as possible.

Call us if your treatment is denied or delayed.

• Please call to discuss any treatment denials. If we can, we will request a hearing to address the denial. We will also discuss what your doctor can do to make their treatment authorization submission better for a re-submission.

If your doctor does not obtain proper authorization or if the treatment does not comply with the treatment guidelines, your doctor might not get paid for their services. However, they are not allowed to bill you for that treatment related to your work injury.

Diagnostic Testing for your Comp Injury

• Carriers can require that you obtain medical such as an MRI or X-rays throughout the carriers treatment work.

More information regarding treatment authorization is available at the Worker’s Compensation Board’s website.

Prescriptions

All prescriptions must comply with the Workers’ Compensation Board’s prescription formulary (list of approved medications). Information regarding the formulary is available here.   There are different rules about what medications can be prescribed within 30 days of your injury, 30 days after your injury, or within 4 days before or after surgery.  

Your medical provider must request approval of any medications outside of the formulary through the Workers’ Compensation Board’s Medical Portal.  That request should be filed up to 30 days before your prescription needs to be filled.  A carrier then has 4 days to approve or deny the prescription.  If the carrier denies the prescription, your doctor must appeal that denial within 10 days.  If your doctor appeals, the carrier then has an additional 4 days to have the prescription request reviewed by its doctor.  If the carrier denies the prescription a second time, your doctor has 10 days to file a second appeal.  It is only then that someone outside of the carrier will review your doctor’s request.  The Workers’ Compensation Board will then issue a decision as to whether your prescription is approved.  

Unfortunately, lawyers cannot appeal most prescription denials.  In fact, we are not even notified that the carrier has denied your doctor’s prescription request.  Your doctor is responsible for getting your prescriptions approved.  

If the carrier denies your prescriptions, call us so we can discuss what your doctor can do to make the prescription request stronger. Then call you doctor and ask them to appeal the prescription denial.

If the carrier provides you with a prescription card, all prescriptions related to your case should be filled through the carrier’s plan.  

Mileage Reimbursement

You are entitled to reimbursement for medically-related travel expenses. 

Consequential Injuries

When your case is established, medical treatment and wage-replacement benefits will cover only the established body parts or conditions. 

Sometimes a work injury can lead to additional injuries or conditions called consequential injuries.  For example, if you have a work-related knee injury and that knee gives out causing you to fall and break your wrist, that wrist could be covered as a consequential injury.  

Similarly, a knee injury may causes a limp and the limp could cause you to develop back problems.  These back problems may be covered under workers’ compensation as a consequential injury.  

 To start a claim for a consequential condition, please provide us with a note from your doctor or nurse practitioner explaining how your work injury led to your consequential injury. Then give us a call so we can discuss the next steps in getting your claim expanded to include your consequential condition. 

The carrier will not have to pay for consequential injuries until those injures are established.

How long will my medical benefits last?

Medical coverage continues for life as long as the treatment is related to your work injury.  If there is a disagreement among the doctors, a judge will decide if the treatment is related.  If you do not see the doctor for an extended period time, insurance carriers are likely to claim that you must have had a new injury.  As such, we recommend you see the doctor at least once a year to document that you are still having problems from your work injury.  

Remember, if you are seeking cash benefits you typically need to see a doctor every 90 days. 

If you change jobs, you will still be covered under workers’ compensation for treatment related to your work injury.

What should I do if I receive medical bills?

If you receive medical bills for your workers’ compensation treatment, tell your doctor that these bills are related to your comp claim. Ask them to send the bills to the carrier. Give the doctor the address of the carrier and your Comp case information.  

If you keep getting bills, send us a copy of the bills. We will write a letter to the medical provider and reminding them that those bills should be sent to the workers’ compensation insurance carrier. 

 

You (or your private insurance) are responsible for any medical bills unrelated to your comp claim.