Defeating Denials: Patients’ Advocates Fight Back Against Insurance Companies

This article explains:

• How insurance companies try to avoid paying for medical recommendations,
• How patients can improve their chances against insurance company stratagems, and
• The role a patients’ advocate can have in the battle against these insurance companies.

A worrying trend across North Carolina and the US as a whole shows insurance companies increasingly trying to deny compensation for medical recommendations from doctors after workplace injuries. In order to avoid having to pay, workers’ compensation insurance carriers will try to force the worker to use their own health insurance or simply give up and return to work.

What Strategies Do Insurance Companies Use To Fight Medical Recommendations?

Insurance companies have many tactics and strategies they use to fight medical recommendations. In the past, they might have debated the cost or necessity of the treatment. However, today they are more likely to simply argue that the treatment is not strictly and exclusively related to the workplace accident or injury in question.

One particularly pernicious strategy that is becoming increasingly popular is the use of nurse case managers. Insurance companies will hire nurse case managers to attend appointments with the injured worker. The nurse case manager then, through the questions they ask, tends to advocate for the doctor’s recommendations to be put on hold a little bit. For example, until some more physical therapies are done or until some more imaging studies are resolved.

If a doctor requests authorization for surgery, it is not uncommon for the nurse case manager to step in and think of ways to slow the process down. For example, by getting a second opinion from a different doctor.

The North Carolina Workers’ Compensation Act allows defendants in any case where the plaintiff is seeking compensation of any kind to force the injured worker to undergo an independent medical evaluation. Clearly, the Independent Medical Evaluation or IME should be independent.

However, over the years, insurance companies have learned that the industrial commission will allow insurance companies to force injured workers to see their doctors and their experts. It will even turn a blind eye to insurance companies speaking to them without the injured worker’s presence in order to build a case about why medical treatment might not be necessary or appropriate.

All this effort just to be able to deny treatments injured workers desperately need to be able to return to work.

How Can I Ensure That My Insurance Company Will Cover Medical Treatments My Doctor Recommends?

What your doctor says and does is often going to be their expert medical opinion and, while it might not always be possible to guarantee their recommendations will be approved, there are steps you can take to improve your chances.

Don’t Neglect Your Strongest Ally: Your Doctor

First, anytime a medical professional provides any kind of treatment, recommendation, or even just information, you should use that opportunity to build a good rapport with the doctor. Later, they can become a strong advocate for you. Most doctors out there do care about their patients first and foremost. If you need your doctor to write a letter, having that good rapport can be critical to make sure that the treatment recommendations will be fulfilled.

A lot of doctors, if they do not have a strong relationship with the patient, will be more willing to let another doctor decide what is needed. When they like and care about you, doctors will go to bat for you and clearly state in their medical records that you need certain treatments and explain why.

Don’t Undermine Your Credibility

Another factor you have to be attentive to is making sure that the insurance company cannot dispute your credibility. You need to make sure that your medical records are correct, so when you report symptoms, complaints, aggravations, and such, it needs to be very clear to the doctors what’s going on.

Any kind of transcription error on the doctor’s side of things where they misheard or miswrote something in a report will often be used against the injured worker. It is vital that, when you speak with the doctor and explain your symptoms, you are clear and consistent. It cannot hurt to have the people taking down notes repeat back exactly what was being talked about and explained so no errors can be used against you by insurance companies to deny or delay your medical treatment.

What Is The Role Of A Patient’s Advocate In Fighting Insurance Companies That Deny Medical Recommendations?

Perhaps the most effective tool when seeking workers’ compensation is a strong lawyer as your patient advocate.

There are several things that an attorney can do on your behalf to help make sure that the medical treatment runs as smoothly as possible. For example, they can insist on an initial meeting between you and the nurse case manager hired by the insurance company to make sure that everyone’s rules and expectations are fully met.

There is a set of rules that the nurse case managers must follow by law as the case progresses. Your patient advocate knows those rules and will hold the nurse case manager accountable. An experienced attorney will force the nurse case manager to consider your interests rather than those of the insurance company. This certainly helps the process go better for you in the long run.

The other thing your patient advocate can do is get the medical records and identify possible errors or issues with those medical records that need to be corrected. This can also be done with the nurse case manager reports. This can avoid information that is incorrectly harming your case or affecting your medical treatment.

Ultimately, if the insurance company is being unreasonable in its denial, an attorney can take the case to the industrial commission. There they can either file a motion or request a hearing to make sure that the necessary medical treatments are approved, authorized, and paid for in a timely fashion and in good faith.

For more information on Strategies To Fight Insurance Companies Denying Medical Recommendations, a free initial consultation is your next best step. Get the information and legal answers you are seeking by calling (833)444-4127 today.