Obtaining Certain Treatment for Workplace Injuries May Require Pre-Approval

Oct 31, 2016 - Workers' Compensation/Work Injury by Cross & Smith

As a general rule, any employee who sustains a workplace injury in Alabama expects to seek immediate treatment under workers’ compensation. However, the Alabama Department of Industrial Relations Administrative Code requires pre-certification in certain relatively-common situations. These requirements can leave injured workers facing significant out-of-pocket expenses.

Still, the rules can be open to a certain degree of interpretation. It helps to become familiar with the pre-certification process that can occur between medical providers and individuals representing the details of claims. Most importantly, injured employees should seek advice from an experienced Tuscaloosa workplace injury lawyer before assuming that they are responsible for personally paying the expenses.

How Pre-Certification Works

Meeting pre-certification requirements is the responsibility of medical providers — not injured employees. Once providers determine that emergency conditions do not apply, the Code requires that they apply for certification before rendering certain medical services, such as (but certainly not limited to) the following:

• Inpatient admission of any type
• Elective procedures, including ambulatory or outpatient surgery
• Outpatient physical, occupational and speech therapy
• Chiropractic services
• Medical management services requested by the employer

The list extends to ambulance services and any number of pain management procedures, durable medical equipment other than items such as braces and splints and items that require reimbursements of $500 or more. Even procedures that injury victims assume to be necessary — such as Magnetic Resonance Imaging (MRI) or Computerized Axial Tomography (CAT) scans that are commonly used diagnostic procedures — can be subject to denial in many cases.

Denial Notifications Go to the Medical Providers

When medical providers request pre-certification, any denials are submitted in writing directly from the employer/agent or certain other officials involved in the claim. If left uncontested, this means that employees may not receive the additional treatment or services unless they choose to pay for them directly. Of course, in the event that medical providers perform services or issue devices that should have been submitted for pre-certification, they are likely to receive denials of payment.

In many instances, medical providers recognize emergency situations, while the individuals who process workers’ compensation claims disagree and deny valid claims. These situations are relatively common, and resolution requires interaction between the providers and the claims officials. Injured employees should not become involved in these disputes.

Unfortunately, some medical providers who lose their disputes may turn to the injured workers when portions of their bills go unpaid. Clearly, medical services and devices are extremely costly. For example, the average price of a single MRI can easily cost over $2,000. After suffering from on-the-job injuries, workers should not pay an additional price due to a possible administrative error on the part of a medical provider. Before paying medical bills in cases like these, employees should seek immediate guidance from an experienced workers’ compensation attorney.

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