LOUISIANA WORKERS COMPENSATION UTILIZATION
Workers Compensation insurance companies often ignore or
deny requests for medical treatment and testing. In fact,
ignored or denied medical treatment is the most common
reason people contact my office for help with their claim.
The Louisiana Administrative Code requires Louisiana Workers
Compensation insurance companies to follow a set of
Utilization Review Procedures when deciding whether to cover
the cost of medical treatment. Requests for surgery and
inpatient hospitalizations follow somewhat different rules
than requests for other types of medical treatment, such as
prescription medication, physical therapy, medical devices
or medical tests (MRI, EMG, CT Scans, etc.).
If the medical treatment involves surgery or an overnight
hospitalization, the doctor’s office will usually provide
the Louisiana Workers Compensation insurance company with basic information about the type
of treatment you need. The insurance company is
then required to immediately begin an investigation to
determine whether they will provide coverage. The
investigation will include obtaining detailed information
from the treating doctor’s office and may include sending
the claimant for a second opinion surgical examination with
a doctor selected by the insurer. If the insurance company
doctor disagrees with the claimant’s treating doctor, then
the claimant or the insurance company may request an
Independent Medical Examination with a doctor appointed by
the Louisiana Office of Workers Compensation.
Once all of the information is available, the insurer must
provide a response within a few days concerning whether they
will cover the cost of the hospitalization or surgery. If
the hospitalization or surgery is denied, the claimant has
the right to file a
Disputed Claim for Compensation with the
Louisiana Office of Workers Compensation to ask a Judge to
determine whether the treatment should be approved.
The process works a little differently for other types of
medical treatment, such as orders for prescription
medication, physical therapy, medical devices, medical tests
(MRI, EMG, CT Scans, etc.) or other treatment that doesn't
require an overnight hospital stay. Requests for these types
of medical care are supposed to be initiated by the doctor’s office
sending the insurance company a report that contains the
- the patient’s history and physical examination results,
including a clinical summary.
- the diagnosis.
- the type of service or treatment the doctor is requesting.
- the plan of care, including the expected length and
frequency of treatment.
- the patient’s prognosis, including the expected outcome of
the treatment or test.
- any test results and interpretations that support
necessity of the treatment requested.
In practice, the doctor’s office will often call the
insurance company on the telephone
to set up the test or treatment. The Workers Compensation
insurance company will often reply: "Send us the request in
writing. Here's the fax number for our pre-authorization
What happens next largely depends upon two things.
First, how thoroughly does the information your doctor
sends to the Louisiana Workers Compensation insurance
company document, explain and support your need for the test
or treatment. In other words, how close does the request
come to actually satisfying the six types of information
Secondly, what is the predisposition of the medical staff
who work for the insurance company to approve or deny the
type of treatment your doctor is requesting. Some types of
treatment are usually approved readily. Other treatment and
tests are usually denied.
The insurance company is required to have nurses available
to review the requests. They often satisfy this requirement
by hiring outside agencies
to perform the reviews. The insurer must approve or deny the
request for treatment or testing within seven calendar days
of the date of that the doctor’s office provides the
required information. If they don’t provide a response
within seven days, you have the right to consider
the request denied and a Louisiana Workers Compensation Judge has the
right to assess penalties against the insurance company for
failing to follow the Louisiana Utilization Review
If the nurse reviewing the claim concludes that the
treatment is not medically necessary, the insurance
company must have the request reviewed by a doctor of the
same medical specialty as the doctor who ordered the test or
treatment. Workers Compensation insurance companies
sometimes call this their "physician advisor." If the insurance company doctor also concludes
that the treatment is not medically necessary, the insurer
is supposed the notify the doctor and claimant in writing
and fax a copy of all of the information they relied upon in
denying the treatment to the Louisiana Office of Workers
Compensation Medical Services Division.
Louisiana Office of Workers Compensation should immediately
review the information and may either:
- Issue an opinion stating that they think the treatment or
test should be approved.
- Issue an opinion agreeing with the insurance company’s
decision to deny the treatment or test.
- Order an
Independent Medical Examination to determine
whether the treatment or test should be approved.
After the Louisiana Office of Workers Compensation issues its
determination, either the claimant or the insurer may file a
Disputed Claim for Compensation with the
Compensation Court. This will ultimately result in a Trial
in which the Judge will be called upon the review the
information and determine whether the treatment should be
If the Judge concludes that the employer or Workers
Compensation insurance company failed to perform the initial
review within seven days of receiving the required
information from the doctor’s office, the Judge can impose a
penalty. Additionally, if the Court finds that the Louisiana Workers
Compensation insurance company “arbitrarily and
capriciously” refused to approve the claimant’s medical
care, the Court can impose an award of attorney fees as an
additional penalty. In order to be successful on a claim for
penalties and attorney’s fees, the claimant must prove that
their doctor submitted all of the required information and
the insurance company acted irresponsibly in failing to
follow the Louisiana Utilization Review Procedures.
Next: Second Medical Opinion