Getting Your Medical Treatment Paid Through Massachusetts Workers’ Compensation

medical-cross-3-971653-m          Massachusetts’ workers’ compensation insurance pays for any medical treatment, tests, procedures and prescription medication that is “reasonable, necessary” and “causally related” to your work injury.  The workers’ compensation insurer will not automatically pay for these medical benefits.  Your medical provider MUST follow certain guidelines in order for the workers’ compensation insurer to pay for your medical treatment or prescriptions.  Here is the general process for your medical provider to follow in order to get your medical treatment and prescription medication approved by workers’ compensation:

  • The medical provider or pharmacy must send a WRITTEN request for authorization to the workers’ compensation insurer and/or the workers’ compensation insurer’s utilization review provider. (The workers’ compensation claims adjuster is not obligated to respond to phone calls seeking authorization if a written request is not sent).
  • Once your medical provider or pharmacy has properly submitted a written request to the workers’ compensation insurer and/or their utilization review provider, the utilization review provider will review the request to determine if the requested treatment or prescriptions are “reasonable and necessary.”
  • Under no circumstances should a medical provider perform any treatment or testing, or dispense any prescription medication without receiving prior approval from the workers’ compensation insurer. This is because if they do, and the request is sent to the workers’ compensation insurer and/or their utilization review provider after the test or procedure was performed, and then it is denied by the insurer, YOU could get stuck with the bill.
  • If utilization review determines that the medical treatment is “reasonable and necessary”, the claims adjuster then has the right to determine whether the treatment is “causally related to the work injury”.
  • The medical provider should never do the treatment or testing without final approval from the workers’ compensation claims adjuster.
  • If the treatment is denied by either utilization review or the workers’ compensation claims adjuster, utilization review and the workers’ compensation insurer must send a written denial notice to your medical provider.
  • If the medical treatment is denied, and the basis of the denial is the worker’s compensation insurer’s assertion that the treatment is not “causally related to your work injury”, then the medical provider can bill the treatment to your health insurer.

**Note:  If the treatment or prescription is denied on the basis that the treatment is not “reasonable and necessary” than your health insurer may also issue a denial for the same reason.

  • If medical treatment is denied, then you need to contact your attorney so that your attorney can file a claim for payment of medical treatment with the workers’ compensation insurer.
  • If you have used health insurance to pay for medical treatment denied by workers’ compensation, your health insurer may attach a lien to your workers’ compensation claim so they can seek reimbursement (in the event that a judge orders the workers’ compensation insurer to pay for the denied treatment at a later date.
  • Your attorney cannot file a claim for payment of “denied” medical treatment or prescription medication without the following documents:
  • A copy of the denial letter sent from utilization review or the workers’ compensation insurer to your medical provider; and
  • A note from the physician prescribing the medical treatment or prescription medication indicating that the denied treatment is “reasonable, necessary and causally related” to your work injury.

Most often, “denied” medical treatment has not actually been denied by the workers’ compensation insurer.  Often times the medical provider, or pharmacy, has not properly followed the guidelines for submitting requests for authorization to the workers’ compensation insurer.  Your attorney can only help you after your medical provider has taken the proper steps to request authorization from the worker’ compensation insurer, and the worker’s compensation insurer has denied (in writing) the medical provider’s request.