Oregon Workers' Compensation Surgery or Treatment Denial
Our experienced workers' compensation attorney in Portland can help you with treatment and surgery denials.
How to Fight a Denied Surgery or Treatment Request in the Oregon Workers' Compensation System
Treatment denials are a common occurrence in the Oregon workers' compensation system. Many workers are surprised when therapy, surgery or an MRI is denied. To make matters worse, insurers rarely explain the basis for their denial and, when they do, the reason they provide is typically poorly articulated or otherwise makes little sense. Like most aspects of workers' compensation dispute resolution, the process of fighting a treatment denial is complex and consultation with a knowledgeable Portland workers' compensation attorney is highly recommended.
Steps in Fighting a Treatment Denial
The first step in fighting the insurer's treatment or surgery denial is gathering any necessary documentation of the treatment or surgery request. It is very important the medical provider maintain a copy of the treatment request along with a copy of any fax transmittal receipts proving it was sent to the insurer or managed care organization (MCO). Telephone logs or other notes confirming the request was sent and documenting the insurer's or MCO's response may also be available. This documentation should be gathered and organized in preparation for filing a Medical Services Dispute or initiating the MCO's dispute resolution process.
File a Medical Services Dispute
Filing a medical services dispute is typically the second step in fighting a treatment or surgery denial when the worker is not subject to a managed care organization (MCO). If the worker is subject to an MCO, the MCO dispute resolution process must be exhausted before a medical services dispute can be filed. Requests for Review through the MCO dispute resolution process must be made to the MCO within 30 days of the mailing date of the initial MCO decision. Once a final decision is issued by the MCO, a Request for Review must be filed with the Workers' Compensation Division's Medical Resolution Team within 60 days of the mailing date of the MCO's decision.
For all non-MCO claims, medical services disputes are resolved by the Workers' Compensation Division's Medical Resolution Team. Importantly, medical services disputes must be filed within 90 days of the date the worker knew or should have known there was a dispute. Filing can be accomplished by filling out a form 2842. Copies of the form 2842 Request for Dispute Resolution can be obtained by clicking here.
The insurer will be asked to provide an initial response to the medical services dispute by completing a Specification of Disputed Medical Issues form. This form provides a basic outline explaining why the medical service was denied. In many instances, the insurer will raise the issue of medical causation, meaning they are disputing the "causal link" between the accepted condition and disputed medical service. In the event causation is challenged, the Medical Resolution Team will transfer the dispute to the Workers' Compensation Hearings Division. A hearing will then be scheduled before an Administrative Law Judge, who will determine whether the requested treatment or surgery is compensable under the claim. Many medical services disputes result in a hearing over the issue of causation. A general overview of the hearing and appeal process can be found by clicking here. Due to the complexity of Oregon's workers' compensation laws and likelihood that a medical services dispute will result in further litigation, Goin Law Group strongly advises speaking with a Portland workers' compensation attorney if a surgery or other medical treatment was denied.
Common Reasons Why Workers' Comp Surgeries are Denied in Oregon
Insurers deny surgeries and other medical treatment for a variety of reasons. It is important to remember that a treatment or surgery denial does not mean the worker has a bad claim or has done something wrong. In some cases, the insurer simply loses the authorization or fails to review it in a timely manner, resulting in a quick denial that the insurer hopes will not be appealed. At other times, the insurer denies treatment in an attempt to force litigation and settlement of a claim they feel has been open too long or will cost too much. Sometimes the insurer is simply mistaken about the facts of the case and issues a denial without carefully reviewing the documentation. Whatever the reason for denial, it is important to remember that a timely appeal of the decision must be made.
Call our Portland Workers’ Compensation Attorney for Assistance with Your Workers’ Compensation Surgery or Treatment Denial Today
Nathan Goin began his career as a claims examiner for one of the major workers' compensation insurers in Oregon. Through this experience, he learned firsthand how workers' compensation insurers view injured workers, manage their claims, value settlements and, ultimately, attempt to close claims while paying as little as possible. Nathan's legal career now focuses on fighting for the rights of injured workers to ensure that they receive the benefits they deserve.
We understand how difficult the workers' compensation process can be for an injured worker. Goin Law Group values every client and will work tirelessly to maximize your benefits. Schedule a free consultation with an experienced Oregon workers' compensation attorney today. Call now for assistance with your claim. You don't have to do this alone.