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Injured NC Workers May Need Preauthorization for Admission or Surgery

By Brown Moore

June 11, 2015

Home News & Resources Injured NC Workers May Need Preauthorization for Admission or Surgery

Under the Workers’ Compensation Act, a workplace injury involving a true medical emergency does not require pre authorization from the insurance company. This same rule holds true for injured workers seeking diagnosis or treatment, regardless of whether the insurer has admitted liability or authorized payment.

In spite of these legal requirements, however, injured employees can unfairly face claim denials for hospital admission or procedures that were not preauthorized. This is the time to call a Charlotte workplace injury attorney who understands the complex rules and knows how to advocate on behalf of workers’ rights — and their health.

How Preauthorization Works

When workplace injuries happen, medical providers must determine how to proceed with patient care essentially based on the medical necessity of surgery or inpatient admission. They can submit a Request for Preauthorization of Medical Treatment, which the insurer must accept no more than 10 days prior to admission or surgery, subjecting the insurer to the following requirements:

  • A response within two business days of the request, which may require an independent examination
  • Determination within seven days of receipt of a preauthorization request, subject to certain allowable delays
  • Documentation of the insurer’s findings to be sent to the employee, the attending physician, and, if applicable, to the hospital or treatment center
  • Authorization to be issued when a second examination supports the need for hospitalization or surgery provided the insurance company does not deny liability.

If a provider fails to meet the preauthorization requirements, the insurer can reduce reimbursement of the provider’s eligible charges by up to 50 percent, although, the injured worker is not liable for this amount. To complicate matters, these basic rules include many exceptions that can help or hinder the rights and even the ultimate health of a workplace injury victim.

Preauthorization Delays Can Affect the Health of an Injured Worker

Of course, not all injuries require emergency surgery, and many patients can receive appropriate monitoring at home rather than from a hospital bed. Still, our Charlotte workers’ compensation lawyers maintain that today’s hospitals do not admit patients on a whim any more than surgeons choose to perform emergency surgeries when they can operate in a more controlled environment by waiting.

When immediate attention is required, the timeframe for obtaining pre authorization and filing possible appeals can seem interminable when every passing day affects the health and safety of an injury victim. Insured workers who believe this process puts them at risk should seek immediate support from an experienced workplace injury attorney. Call us at 800-948-0577 or use our convenient online contact form to learn how we can help.