MY DOCTOR WANTS THE INSURANCE CARRIER TO GIVE WRITTEN AUTHORIZATION BEFORE PERFORMING SURGERY, EVEN THOUGH THE SURGERY REQUESTED IS PRE-AUTHORIZED, BUT THE INSURANCE CARRIER REFUSES. NOW WHAT?

Since their establishment, the new Medical Guidelines have been both a blessing and a curse.  Although the goal was to:

• Set a single standard of medical care for injured workers,
• Expedite quality care for injured workers,
• Improve the medical outcomes for injured workers,
• Speed return to work by injured workers,
• Reduce disputes between payers and medical providers over treatment issues,
• Increase timely payments to medical providers, and
• Reduce overall system costs.

that was not all that it did.  It also created a climate of distrust by doctors, who refuse to provide even the pre-approved treatments under the guidelines without written pre-authorization by the insurance Carrier themselves.   The guidelines foresaw this issue, and provided solutions as follows:

A. Pre-authorization (C4AUTH): For treatment of injuries to the mid and low back, neck, knee, shoulder and Carpal Tunnel Syndrome, pre-authorization is only required for procedures listed in question #1 Pre-Authorization. The pre-authorization process, used for treatments or procedures exceeding a $1,000 threshold, continues to be used for all other body parts. The pre-authorization process uses the C-4 AUTH form and it gives the carrier 30 days to respond to a request. During that period, the carrier has the right to obtain an IME or records review. To deny a pre-authorization request, the carrier must show a conflicting medical opinion.

B. Optional Prior Approval (MG-1):This process is more limited in focus, and is designed to only answer one question, "is the requested treatment or test a consistent application of the guidelines?" Providers must electronically submit the (MG-1) form. Carriers have eight business days to respond. Disputes are resolved by a binding decision of the Board's Medical Director's Office. The process allows medical providers to obtain a determination prior to treating on whether the requested treatment is consistent with MTG recommendation. It allows carriers to object before a test or treatment is performed.

But here is the catch: Although the regulations provide for an optional prior approval procedure where the medical provider can request optional prior approval from a PARTICIPATING insurance carrier to determine correct application of the Guidelines (A Board form (MG-1) is available for this purpose on the Board's web site), this process is only available if the insurance carrier or employer is participating in the optional prior approval program. A list of insurance carriers and employers who have opted out of the optional prior approval process is available on the Board's web site. Search for Carrier Contacts and Participation.  .  An insurance carrier who is not participating is not required to respond to an Optional Prior Approval request.

Somehow, many doctors, often due to the policy of certain hospitals, refuse to perform treatments such as surgeries without pre-authorization, and given that the Carrier is not required to give such authorization in writing, the Claimant suffers.   Ifa carrier has opted out of the Optional Prior Approval program, the Board will not respond to MG-1 requests submitted by the claimant's medical provider. Medical providers are encouraged to treat the claimant in accordance with the Medical Treatment Guidelines and submit timely bills to the carrier or self-insured employer.  Hospitals and treating physicians must familiarize themselves with the law and understand that the Carrier CANNOT DENY PAYMENT FOR TREATMENTS PRE-AUTHORIZED UNDER THE GUIDELINES.  As an attorney, I often find myself being the voice of reason with doctor's offices, but it doesn't always work.  Often times this means a switch in doctor is warranted.