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Dawn Atkin

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Posts: 37
Disputes over surgery are very common in Utah Workers Compensation cases.  When the treating doctor requests pre-authorization from the adjuster, the adjuster has four days to respond.  Unfortunately, there is currently no penalty when adjusters ignore this deadline and take weeks or months to pre-authorize or deny the recommended care.

We do not recommend that you allow long delays in care.  Surgery is less effective when delayed.  Serious complications can occur.  You can push for action.

1.  Call the adjuster if there is no response to the surgery pre-authorization within a week.  Usually, we find that, for whatever reason, the adjuster did not receive the request from the doctor and it needs to be re-sent.  In some cases, the adjuster is waiting for some additional information from the doctor and you can ask the doctor's office to act quickly to provide the information.

2.  Sometimes, the Utah Labor Commission, which governs workers compensation in Utah, will contact an adjuster to remind them of the deadlines for responding to the pre-authorization request.  Call them at (801) 530-6800 and let them know the adjuster will not respond to the pre-authorization request for surgery.  This does not always work, but it is worth a try. 

3.  If there is no response to the pre-authorization request within two weeks and your calls to the adjuster go unanswered, call us.  Legal action will be needed.  (801) 521-2552.

4.  If the adjuster responds with a denial of the surgery, you can proceed through your private health care, Medicaid or self pay.  This might require changing doctors due to network requirements.  Carefully keep track of all out of pocket payments in order to request reimbursement.  Again, contact us to assist you in filing a legal action to recover the costs of the surgery for you and your private health care, as well as payment for the time off work after surgery and permanent injury.  Read our posts about Temporary Total Disability and Permanent Partial Disability for more information on these benefits.

Your private health care will tell you that they do not pay for workers compensation injuries.  That is right, but the workers compensation insurance is claiming the surgery is not work related (the only basis for not approving the surgery).  Be sure to notify your private health care that your workers compensation carrier has refused to cover the surgery, so you need to proceed through private health care.  Provide all the information they request about your workers compensation insurance company.  They have the right to fight to get their money back too.

K. Dawn Atkin
Attorney with Atkin & Associates
(801) 521-2552
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