When you are injured on the job, you have to go through the workers’ compensation insurance system. There are benefits to this, the most obvious being that your medical care is paid for. However, there are disadvantages to this system as well. It relies on a great deal of paperwork that can be difficult to navigate without experience or legal knowledge. It also gets your employer involved in your medical care, particularly if your employer is self-insured.
Since paperwork may go through your employer or a managed care organization (MCO), you might naturally wonder whether your employer can choose your physicians and limit your medical treatments. While your options may be restricted under the Ohio workers’ compensation system, you have the right to work with an approved physician and receive appropriate medical care. That being said, some employers and MCOs will try and limit additional medical services for financial reasons.
If you are having trouble getting your medical treatments approved or paid for, contact the certified workers’ compensation attorneys Victor Kademenos and Adrienne Hines of Kademenos, Wisehart, Hines, Dolyk & Wright Co. LPA at (419) 625-7770 to learn about your options.
You Can Choose Your Physicians
Some employers might make it sound like you must go to a certain doctor. However, you have the right to go to any physician certified by the Ohio Bureau of Workers’ Compensation (BWC). If you are not sure whether your general physician is BWC-certified, you can use BWC’s online certified provider look-up. If you want to change to a different BWC-certified doctor, you will have to notify the MCO or your employer, if it is self-insured.
The Authorization Process Can Lead to Limitations
Under the workers’ compensation process, many medical services do not need prior authorization. For instance, if you need to go to the emergency room or you visit your physician and need a basic X-ray, you do not have to request that this service is approved beforehand. You simply file the claim afterward. Also, the services provided to you within the first 60 days following a soft tissue or musculoskeletal injury are presumed approved if certain conditions are met.
However, some doctor’s visits and treatments must be approved by an MCO involved in your case beforehand, otherwise, it will not be paid through the workers’ compensation system and you could be responsible for the final bill. The MCO assigned to your employer is the organization that will make your medical treatment decisions and you had better get to know it well.
The authorization process can be complicated. Contact a certified workers’ compensation specialist from Kademenos, Wisehart, Hines, Dolyk & Wright Co. LPA today at (419) 625-7770 for help.
How Your Medical Decisions Are Made
The MCO relies on medical professionals to review your case and determine whether a proposed service should be covered or not. Approval or denial will depend on your condition, the services you previously received, and whether the proposed service is necessary and the cost is medically reasonable. If the MCO is not sure, you may be asked to undergo an independent medical examination (IME) or provide additional documentation. The MCO has three business days to make a decision or if it needs more information, within five business days of receiving additional documentation.
Appealing a Denial
Once the MCO makes a determination about a requested service, it sends its recommendation to the BWC, which then sends you a letter about the decision. If a treatment or service is denied, you have 14 days to appeal the decision.
To appeal a denial for a treatment, you will need to go through the MCO’s appeal process. It is best to work with a certified workers’ compensation attorney for this. Your appeal will go through the MCO’s alternative dispute resolution process. You and your attorney will have to prepare for a negotiation on why you believe the treatment should be approved, which will need to focus on why it is both necessary and appropriate.
Dealing With a Self-Insured Employer
Your workers’ compensation journey will be different if your employer is self-insured. If your employer is self-insured, you may be required to go to its specified physician for your initial visit. After this, you can go to any BWC-certified doctor. You will also have to go through your employer for treatment authorization instead of a MCO. Your employer has 10 days to approve or deny a treatment.
If your employer is self-insured and you are having trouble receiving the care you need after a work-related injury or medical condition, contact the Ohio workers’ compensation attorneys of Kademenos, Wisehart, Hines, Dolyk & Wright Co. LPA at (419) 625-7770 right away.
Do You Need Help With an Ohio Workers’ Compensation Issue?
Ohio’s workers’ compensation insurance can be difficult and stressful. While it is meant to ensure workers like you are taken care of, MCOs and self-insured employers have a financial bottom line to protect and can try to limit your medical care. By working with certified workers’ compensation attorneys Victor Kademenos and Adrienne Hines, you ensure you are not wrongfully denied necessary medical care. You have experienced lawyers on your side who can skillfully navigate the claims and appeal processes.
To learn more about how we can help, call us at (419) 625-7770 and schedule a free consultation.