Delays in getting medical care authorized are the reason most injured workers contact me for help on their claim. Here is some additional information about treatment delays and what you can do to get proper medical care on time on your Nevada workers’ compensation claim.
- An insurer won’t authorize expensive tests like MRI’s or EMG/nerve conduction studies until the insurer decides to accept your claim. The adjuster has 30 days to accept or deny the claim. If the claim is denied, no tests or further treatment will be authorized.
- Prior authorization must be sent by your treating doctor to the adjuster for diagnostic tests (other than in-office x-rays), physical therapy, consultations with other doctors, or for surgical procedures.
- The adjuster has 5 working days to respond to a doctor’s request for authorization pursuant to NRS 616.157.
- Insurers can delay treatment or tests by scheduling an injured worker for a consultation or an independent medical exam with a doctor chosen by the adjuster. The adjuster can suspend your benefits for non-cooperation if you don’t attend this appointment. NRS 616C.140.
- The insurer can delay authorizing treatment or diagnostic testing until the requesting doctor provides the adjuster with his dictated medical report.
- The insurer might have a medical review done of the request.
- An adjuster should copy you on any denial of the requested treatment or test. and give appeal rights instead of just notifying the doctor of the denial. NAC 616C.091(3).
- If you moved outside of Nevada, the insurer won’t authorize medical care with an out-of-state doctor until the insurer is sure that the doctor will accept what the Nevada medical fee schedule allows for office visits and treatment.
- What you can do:
- Make sure that your doctor faxed the request for prior authorization to the adjuster.
- If the adjuster hasn’t acted within 5 working days, and doesn’t give you a reason for the delay, you may file a complaint with the DIR, with a copy to the adjuster. Some adjusters will then respond, not wanting to deal with a DIR investigation. See NAC 616C.092.
- File an appeal if you have requested a transfer of doctors or some particular treatment. File appeals of any medical review doctor’s opinion denying the requested treatment or test. You may appeal an insurer’s failure to respond to your written request after 30 days.
- You may ask your doctor for help by having him talk to the adjuster to explain why treatment or testing is necessary.
- Make sure that your out-of-state doctor will accept the Nevada fee schedule before you ask the adjuster to allow treatment with that doctor.
- Get legal help if there are delays that prevent you from getting the medical care you need now for all of your injuries. Most attorneys do not charge for an initial consultation.
