Getting Physical Therapy Paid For By Workers Compensation
Physical therapy, or PT for short, is a widely used treatment that doctors prescribe. Physical therapy is prescribed by doctors as a medical treatment for a variety of workplace injuries.
In a workers’ compensation claim, it is one of the most typical types of medical treatment. Physical therapy may be prescribed by your doctor immediately following an injury. After surgery, your doctor may recommend physical therapy to help you recover from the procedure and regain muscle strength.
If you need physical therapy because of a workers’ compensation injury, the basic idea is that workers’ compensation covers that medical treatment. Of course, you must follow some basic rules to get that treatment covered.
An authorized treating doctor must order the physical therapy. Workers’ compensation should cover the physical therapy if you have filed a workers’ compensation claim through your employer. Your employer is required to provide you with a claim number for you to use when you receive treatment for an injury sustained at work. But, some workers’ compensation insurance companies delay or deny your physical therapy. This delay and denial can hurt your recovery from your injury.
Since physical therapy is pretty routine treatment, why would I have difficulty getting it approved?
Years ago, insurance companies almost always approved physical therapy when the doctor ordered it. However, insurance companies have started fighting about physical therapy a lot more in recent years.
Here is what happens a lot. You see your doctor for an office visit, and your doctor orders your physical therapy. Someone at the doctor’s office either tells you that they will set it up or tells you to take it to a physical therapy provider to set it up.
A week later, your physical therapy has still not been scheduled. Most often, your physical therapy will not be scheduled until the insurance company gives approval.
How does the workers' compensation insurance company deny physical therapy?
When you contact us to start physical therapy, we will want your worker’s compensation claim number, along with some other basic information. We will want to get approval from the insurance company before scheduling your physical therapy. Sometimes, an insurance company may deny approval for you to get the care that you need.
The insurance company can deny your medical treatment in two basic ways:
- They actually deny your treatment. The insurance company does this by telling the physical therapy office that they are denying the request for treatment
- The insurance company just does not give approval for the treatment (although they do not actually deny it)
What happens if the insurance company denies treatment?
If the insurance company denies the request for treatment, we can not schedule the treatment. You will probably need to get some help to make the insurance company pay for the physical therapy. If you don’t have a lawyer, we will gladly refer you to a lawyer that we know and have worked with in other cases like yours.
But, what happens when the insurance company does not deny the treatment but just does not give approval? Unfortunately, the effect on you is pretty much the same because you do not get the physical therapy recommended by your doctor.
What if the insurance company does not approve as much physical therapy as the doctor ordered?
One other thing that you must watch out for is a partial approval. This happens a lot with physical therapy. Your doctor may order a certain amount of physical therapy, but the insurance company does not approve the full amount.
Take this example. The doctor orders physical therapy three times a week for 4 weeks. The insurance adjuster approves physical therapy two times a week for four weeks.
This is an example of partial approval. It is in your best interest of your health to get as much treatment as you need in order to feel better.
Remember that partial approval is really partial denial because the insurance company has denied part of the doctor’s recommendations. Because of that, you should treat it like any other denial of physical therapy and fight to get the doctor’s recommendations approved.
What evidence does the insurance company need to deny my physical therapy?
It would be nice if there was a standard that said the insurance company has to approve the physical therapy unless they have certain evidence to deny it. Delaware workers’ compensation law does not have that standard right now. So, the insurance company does not have to have certain evidence to deny or delay your treatment.
Sometimes, insurance companies will get utilization review opinions from a doctor or other medical provider saying that you do not need physical therapy. Other times, they will send questionnaires to the treating doctor or get a second opinion to try to deny your treatment. The insurance company may also just refuse to provide approval without getting any evidence at all.
Whether the insurance company gets evidence or not, the result to you is the same. You face an obstacle getting the treatment you need to recover from your injury.
What can I do to get my physical therapy approved?
The first step is to talk to us! We are here to help YOU and get you the help that you need.
Our billing department will do all the work (once you provide your workers claim information, and we will let you know that:
· We have requested approval from the insurance company
· We have received an answer from the insurance company
· If we have received an answer, what was the answer
Often, your next step will be to contact the insurance adjuster to ask them to approve the physical therapy. Hopefully, that will correct the situation, but the insurance adjuster may refuse to approve the treatment or give you an excuse.
If this happens, you may need to do more. When the insurance company does not pay for physical therapy voluntarily, you can take measures to force them to pay for that treatment. Some of the measures you can take include:
· Filing a motion or a Form WC-PMT to get the treatment approved
· Asking the doctors office to file a Form WC-205 requesting approval
· Requesting a hearing in front of a judge to get approval
Sometimes, you have to go one of these routes to get approval. If you do, we suggest that you talk to an attorney to find out the best option for you and to decide if you need to hire one to pursue one of these options.
What can I do to get my physical therapy approved?
Delaware’s worker’s compensation system can be very confusing. You have to worry about getting the treatment you need and paying your bills while also worrying about not missing any deadlines that could cause you to lose your right to receive workers’ compensation benefits.
If you have questions, we would recommend that you try to get answers. To find out more about how to schedule a time to talk to us about your worker’s compensation questions, call 302-234-2288 and ask for the billing department.