How long it takes for workers’ comp to approve surgery depends on factors such as obtaining employer approval. According to the National Academy of Social Insurance, employers spent $100.2 billion on workers’ compensation costs in 2019. The Illinois Workers’ Compensation Act requires employers to pay for the reasonable and necessary medical expenses associated with the treatment of injuries suffered on the job. However, employers or their insurance carriers sometimes deny preauthorization requests for procedures, including surgery.
Authorization for Surgery on Workers’ Comp
Although typically covered by workers’ comp benefits, surgeries recommended by health care providers for injured employees generally need preauthorization. Preapprovals serve as a sort of agreement between the payers and the medical professionals to provide payment for the services rendered. Unfortunately, when employers deny such requests, it potentially prolongs workers receiving the care they need.
The authorization process largely evolved out of how many medical professionals and facilities conduct their business. Before they agree to perform costly procedures, such as surgeries, health care providers, hospitals, and clinics typically want to know they will receive compensation from their patients’ insurance providers – whether industrial or private.
Independent Medical Exams
An independent medical exam serves as a sort of second opinion. When considering authorization for workers’ comp surgery requests, some employers or insurers ask employees to submit to these independent reviews. Performed by a health care provider of the company or insurance carrier’s choosing, independent medical exams may include additional office visits, imaging, or testing. In Chicago, many workers’ compensation lawyers caution that requests for independent medical exams sometimes signal an employer is looking to deny the pending claim. Some physicians who regularly conduct these types of examinations may have financial incentive to give opinions and reports that favor the financial interests of the insurers, not the injured workers.
Reasons for Denying Surgery for Injured Workers
In determining whether treatment qualifies for workers’ compensation coverage, the Commission considers three primary criteria – causation, potential efficacy, and whether the performing provider’s authorization status. Even if recommended by a licensed health care provider and medically necessary, issues with these criteria may result in the denial of surgery authorization requests.
Occupational injury benefits only cover medical treatment needed as a direct result of a workplace accident or qualifying working conditions. Therefore, employees may need to provide proof their injuries happened on the job to have surgical procedures approved. Insurers typically only approve those proposed surgeries likely to cure the injured workers’ conditions, or at least let them resume suitable work.
As part of their workers’ compensation coverage, many employers require employees to receive treatment from a physician on an approved list they provide. When considering whether to authorize payment for surgery, insurers consider if the treating medical professional is on the employer’s physician panel. If not, it may give cause to deny injured workers’ surgery preauthorization requests. Employees should keep in mind, however, they may change providers if they are not happy with the care they receive. The state’s program allows them one free change to another employer-approved doctor. Alternatively, people may choose to seek treatment using their personal insurance benefits to work with a doctor of their own choosing.
Appealing Denied Surgery Requests
Should insurers deny injured workers’ preauthorization requests, the workers may appeal the decision to the Illinois Workers’ Compensation Commission. A Commission-appointed arbitrator will review the facts of such cases, sometimes asking for additional information or exams. Employees who disagree with the decisions of arbitrators have the right to appeal the decision to a panel of three commissioners. After reviewing written arguments from each side and hearing oral arguments, the panel will issue a decision.
Should injured workers still disagree with the panel’s decision, they may take the matter to the court system. Employees have the right to pursue such cases in the local circuit court, and if necessary, may progress to the state’s appellate or supreme courts.
Just as they may when dissatisfied with their care, injured workers may also take matters into their own hands when awaiting a decision on a surgery authorization claim. In some cases, people who suffer occupational injuries obtain the care recommended to them from their treating physicians using their private insurance policies. Although this may allow them to get the surgeries that they need sooner than waiting out the process, it sometimes causes complications with their claims. Thus, before taking this step, people may consider seeking professional counsel to understand how it will affect their rights and options moving forward.
Factors Weighed When Considering Surgery Requests
A Commission arbitrator, or a panel of the commissioners or a court judge, will consider several factors when determining if insurers should pay for recommended surgical procedures. The considerations weighed include matters such as the reasonableness of the procedure, the likelihood of a successful outcome, and the associated risks. For example, injured workers may have better odds of gaining approval for more common procedures, those with higher percentages of success, and surgeries with limited risks. The arbitrator may also account for the previously discussed criteria for approving surgeries in making decisions about whether to order payment for procedures or not.
Consequences for Employers Delaying Approval
Employers who unnecessarily delay or wrongly deny surgery benefits to injured workers do not face formal sanctions. However, employees have the right to pursue legal action under some circumstances. When employers intentionally and unreasonably delay payment, injured workers may receive compensation of 50% of the amount payable under the act at the time of the award.
Sometimes workers need surgical intervention to repair injuries suffered on the job, or they may need further care after an issue like medically necessary plastic surgery goes wrong. Those who find themselves in such circumstances and face pushback from their employers’ insurance carriers may benefit from understanding their rights and options.