Why won’t the insurance company “preauthorize” my surgery?

When you’ve been injured in Vermont and have filed a workers’ comp claim, there may come a time when your doctor wants to perform surgery, an injection, or some other relatively expensive treatment that requires the insurance company to “preauthorize” that treatment.  Although Vermont law doesn’t require your doctor’s office to request preauthorization, most doctors’ offices request preauthorization from the workers’ comp insurance company to ensure their bill will be paid.  Otherwise, they might perform an expensive surgery and send their bill to the insurance company, only to have it denied.

When your doctor’s office wants to preauthorize surgery, a number of specific things must happen using a very specific timeline.  First, the doctor’s office must submit a written preauthorization request to the insurance company.  Although no specific form is required, the Department of Labor provides this Medical Provider’s Preauthorization Request for doctors to use.  Your doctor’s office must submit that form in writing along with medical records supporting your need for that treatment.

Once the insurance company receives the request to preauthorize treatment, it has several options.  Ideally, the insurance company will simply approve the preauthorization request so that your surgery, injection, etc. can move forward.  The insurance company is permitted up to 14 days to preauthorize treatment after receiving a preauthorization request.  If it has a valid basis for doing so, the insurance company also has the option of denying the preauthorization request, which also must occur within 14 days of its receipt of the request.

The third — and most time-consuming — option is the insurance company can schedule an Independent Medical Evaluation or a medical records review before deciding whether to preauthorize the treatment.  If the insurance company goes that route, it still must notify you and the Department of Labor within 14 days of receiving the preauthorization request.  However, doing so will then allow it to delay its decision for up to 45 days from the date it received the preauthorization request.  If an IME is scheduled, you will likely be required to attend.  If a medical records review is arranged, the insurance company will simply hire an “expert” to review your past medical records and provide an opinion on whether the requested treatment is reasonable and necessary.

If an insurance company has denied your doctor’s preauthorization request, call a Vermont workers’ comp lawyer for assistance with appealing that denial.