Have you ever been in a situation where your doctor has ordered a crucial medical test, but your adjuster was not approving the test ordered by the doctor? It can be incredibly frustrating and leave you wondering why they are denying you the necessary care. Well, you’re not alone. Many people face this issue, and understanding the reasons behind these denials is essential in advocating for your health.
In this article, we will delve into the common reasons why insurance adjusters may deny test approvals. By understanding these factors, you can be better prepared to challenge denials and ensure that you receive the necessary tests for accurate diagnosis and effective treatment.
Why Would an Adjuster Not Approve a Test?
There’s no simple answer to this but here are a few possibilities. First, they’re lazy or procrastinating or overworked. Maybe.
Second, they’re in denial that the test is actually necessary. They may be hoping that you spontaneously get better without the test. That occasionally happens but not often. Most experienced workers’ compensation doctors aren’t just ordering tests randomly. They typically don’t order tests they don’t think are necessary. But some adjusters act like they know more about modern medicine than someone who went to medical school.
Third, they may have an internal review that has to be done before the tests can be authorized. Some insurance companies have an internal “utilization review” performed by an in-house “doctor” to second guess the doctor who ordered the tests.
Fourth, the adjuster may be trying to line up a second opinion with another doctor who may say the test isn’t necessary. You may ask yourself: would an adjuster really pay an extra month of weekly benefits, pay hundreds of dollars to a rehabilitation nurse to set up a second opinion, and pay hundreds more outside of the Industrial Commission medical fee guidelines, just in the hope of avoiding a $750 test? The answer is yes.
What are Possible Strategies for Advocating for the Approval of Medical Tests?
When it comes to advocating for the approval of medical tests, there are several strategies that can be employed to increase the chances of getting the test approved by the adjuster. Here are a few possible strategies:
1. Provide Detailed Medical Documentation
One of the most important strategies is to gather and provide detailed medical documentation that clearly supports the need for the test. This can include medical records, test results, and expert opinions that explain the medical necessity of the test and its potential impact on the patient’s diagnosis and treatment.
2. Communicate with the Adjuster
It is crucial to establish open lines of communication with the adjuster handling the case. This can be done through phone calls, emails, or in-person meetings. By explaining the importance of the test and providing supporting evidence, it may be possible to convince the adjuster of its necessity.
3. Engage in Dialogue with the Doctor
It is important to work closely with the doctor who ordered the test and seek their support in advocating for its approval. The doctor can provide additional information, clarification, and medical reasoning that can strengthen the case for the test.
4. Involve a Patient Advocate or Medical Professional
In some cases, involving a patient advocate or a medical professional who specializes in insurance claims can be beneficial. These individuals can provide guidance, support, and expertise in navigating the insurance process and advocating for the approval of the test.
5. Appeal the Decision
If the initial request for the test is denied, it is possible to appeal the decision. This involves submitting additional documentation, providing further justification, and presenting a strong case for why the test is necessary. The appeals process may vary depending on the insurance provider, but it is an important step in advocating for the approval of the test.
Should You Contact an Attorney?
If you find yourself in a situation where the doctor has ordered a test, but the insurance adjuster isn’t approving it, you may be wondering if it’s time to contact an attorney. While not every situation requires legal intervention, there are certain circumstances where obtaining legal advice can be beneficial.
But generally, if the adjuster is not approving a test that your doctor has ordered, it may be in your best interest to contact an attorney. They can guide you through the legal process, advocate for your rights, and help ensure that you receive the necessary medical treatment.
