LOUISIANA WORKERS COMPENSATION UTILIZATION REVIEW

Louisiana Workers Compensation insurance companies often ignore or deny requests for medical treatment and testing. In fact, ignored or denied medical treatment is the most common reason people contact my office for help with their claim.

The Louisiana Administrative Code requires Louisiana Workers Compensation insurance companies to follow a set of Utilization Review Procedures when deciding whether to cover the cost of medical treatment. Requests for surgery and inpatient hospitalizations follow somewhat different rules than requests for other types of medical treatment, such as prescription medication, physical therapy, medical devices or medical tests (MRI, EMG, CT Scans, etc.).

If the medical treatment involves surgery or an overnight hospitalization, the doctor’s office will usually provide the Louisiana Workers Compensation insurance company with basic information about the type of treatment you need. The insurance company is then required to immediately begin an investigation to determine whether they will provide coverage. The investigation will include obtaining detailed information from the treating doctor’s office and may include sending the claimant for a second opinion surgical examination with a doctor selected by the insurer. If the insurance company doctor disagrees with the claimant’s treating doctor, then the claimant or the insurance company may request an Independent Medical Examination with a doctor appointed by the Louisiana Office of Workers Compensation.

Once all of the information is available, the insurer must provide a response within a few days concerning whether they will cover the cost of the hospitalization or surgery. If the hospitalization or surgery is denied, the claimant has the right to file a Disputed Claim for Compensation with the Louisiana Office of Workers Compensation to ask a Judge to determine whether the treatment should be approved.

The process works a little differently for other types of medical treatment, such as orders for prescription medication, physical therapy, medical devices, medical tests (MRI, EMG, CT Scans, etc.) or other treatment that doesn't require an overnight hospital stay. Requests for these types of medical care are supposed to be initiated by the doctor’s office sending the insurance company a report that contains the following information:

• the patient’s history and physical examination results, including a clinical summary.
• the diagnosis.
• the type of service or treatment the doctor is requesting.
• the plan of care, including the expected length and frequency of treatment.
• the patient’s prognosis, including the expected outcome of the treatment or test.
• any test results and interpretations that support the medical necessity of the treatment requested.

In practice, the doctor’s office will often call the insurance company on the telephone to set up the test or treatment. The Workers Compensation insurance company will often reply: "Send us the request in writing. Here's the fax number for our pre-authorization department."

What happens next largely depends upon two things.

First, how thoroughly does the information your doctor sends to the Louisiana Workers Compensation insurance company document, explain and support your need for the test or treatment. In other words, how close does the request come to actually satisfying the six types of information listed above. 

Secondly, what is the predisposition of the medical staff who work for the insurance company to approve or deny the type of treatment your doctor is requesting. Some types of treatment are usually approved readily. Other treatment and tests are usually denied.

The insurance company is required to have nurses available to review the requests. They often satisfy this requirement by hiring outside agencies to perform the reviews. The insurer must approve or deny the request for treatment or testing within seven calendar days of the date of that the doctor’s office provides the required information. If they don’t provide a response within seven days, you have the right to consider the request denied and a Louisiana Workers Compensation Judge has the right to assess penalties against the insurance company for failing to follow the Louisiana Utilization Review Procedures.

If the nurse reviewing the claim concludes that the treatment is not medically necessary, the insurance company must have the request reviewed by a doctor of the same medical specialty as the doctor who ordered the test or treatment. Workers Compensation insurance companies sometimes call this their "physician advisor." If the insurance company doctor also concludes that the treatment is not medically necessary, the insurer is supposed the notify the doctor and claimant in writing and fax a copy of all of the information they relied upon in denying the treatment to the Louisiana Office of Workers Compensation Medical Services Division.
 
The Louisiana Office of Workers Compensation should immediately review the information and may either:

• Issue an opinion stating that they think the treatment or test should be approved.
    
• Issue an opinion agreeing with the insurance company’s decision to deny the treatment or test.
    
• Order an Independent Medical Examination to determine whether the treatment or test should be approved.

After the Louisiana Office of Workers Compensation issues its determination, either the claimant or the insurer may file a Disputed Claim for Compensation with the Louisiana Workers Compensation Court. This will ultimately result in a Trial in which the Judge will be called upon the review the information and determine whether the treatment should be approved.

If the Judge concludes that the employer or Workers Compensation insurance company failed to perform the initial review within seven days of receiving the required information from the doctor’s office, the Judge can impose a penalty. Additionally, if the Court finds that the Louisiana Workers Compensation insurance company “arbitrarily and capriciously” refused to approve the claimant’s medical care, the Court can impose an award of attorney fees as an additional penalty. In order to be successful on a claim for penalties and attorney’s fees, the claimant must prove that their doctor submitted all of the required information and the insurance company acted irresponsibly in failing to follow the Louisiana Utilization Review Procedures.

Next: Second Medical Opinion