Pre-Authorization of Medical Services
By Brian M. Solodky, Attorney at Law
It is no secret that Oregon claim professionals must contend with a multitude of deadlines related to virtually ever aspect of processing an accepted claim. Failure to meet certain deadlines creates exposure to penalties and fees. As we have all seen over the past few years, injured workers and their attorneys are very aggressive about seeking penalties and fees for virtually any failure to meet a deadline set forth in ORS Chapter 656 or OAR 436. Now even some medical providers are filing their own disputes with WCD over delayed responses to authorization requests. The focus of this article is timelines to address requests for medical services.
The general rule is a claim processor is only obligated to provide or deny pre-authorization for two specific medical services: diagnostic imaging studies and elective surgeries. Claim processors have 14 days to respond to a request to pre-authorize imaging studies. The deadline to respond to a proposal for elective surgery is seven days. Failure to respond within seven days to a request to authorize elective surgery creates penalty/fee exposure and prevents the employer/insurer from later disputing the reasonableness and/or necessity for the procedure. The typical form used to address elective surgery authorizations is WCD Form 3228.
It goes without saying that claim professionals are bombarded with requests to pre-authorize services that do not qualify as diagnostic imaging or elective surgery. Most of these requests can be addressed with a simple explanation to the provider that Oregon law does not require pre-approval of the proposed service and any invoices will be processed within 45 days of receipt. That said, there is a duty to address the pre-authorization request directly if it is established the provider refuses to see the injured worker absent pre-approval. How best to handle these situations can be complex and you may want to consult legal counsel.
The Oregon workers’ compensation system’s primary function is to facilitate the care of injured workers and delaying medical services can prolong the life of a claim, or impede the injured worker’s recovery. Careful consideration should go into any denial of pre-authorization for medical services in general because there are occasions when the causal relationship between the proposed service and the compensable injury is questionable. The key is to focus on ensuring compensable injuries are timely and effectively treated. Keeping these legal deadlines in mind should serve the dual purpose of helping injured workers get better faster and avoiding penalties for alleged unreasonable claim processing.