Work Comp

What is the name of your state? California
If you have Work Comp benefits and WC stops one of your benefits (chiropractic care) can you use your Medical insurance benefits for this benefit? Without jeopardizing your WC case??

CA - to answer you directly...you can certainly try but once the insurance co finds out that your treatment relates to a work-related injury they'll try to get reimbursed from them and the WC carrier will deny it then they may come back to you.

Some other questions though, have you settled your claim by Stipulations? If so, what %?

The insurance carrier has some requirements on it when a med provider requests authorization for medical treatment. Once the request is made in writing by fax or mail the carrier has 5 days to respond. Usually they'll send thru their Utilization Review provider who will review the request and may even contact your dr to get more info if not available on the face of their request. If they don't get it or get enough they'll give to a Dr to review for non-certification. To delay, deny or modify a request for med treatment must be done by a physician. If the Dr. agrees and says their requests is non-certified (for whatever reason) the carrier can still authorize but will usually deny the request.

The dr's office can submit more infor for reconsideration with 5 more days and another decision will be generated on certification. Also, if you disagree with a decision regarding medical treatment (usually non-certification) you may object with 20 days of the Ins Co's denial and get a Panel Qualified Medical Evaluation to resolve the issue. OR...if you've already had a Panel QME you'd go back to that Dr. for an opinion on the care requested. If you were represented by an attorney you'd go back to an Agreed Medical Evaluator.

The law has changed and the primary treating physician no longer has the presumption of correctness. Now guidelines called ACOEM - American College of Occupational and Environmental Medicine are deemed presumptively correct. They can be rebutted but only by peer-reviewed, evidence based medicine.

Either way, you have recourse. Hope this helps.

WC and Med Ins

CA Rosie Thanks for the input..If the WC MD is denying any further chiropractics can i not get a copy of his denial from my medical record where he notates "NO MORE CHIROPRACTICS" and would not the Medical MD accept that and then be OK to refer to treat as long as there are Chiro Bene's available? If the Medical MD refers and the CHIRO bills for pymt and the claim denies for WC and then they go to the WC MD and he confers that he denies any further CHIRO, then won't the CHIRO be ok to treat and get paid by the Medical Ins?? Sorry this is so long, but it worked out at lot easier in my mind. Thanks again!!undefined

I assume you mean if you show the chiro and your insurance the denial from the WC carrier then they should pick up your chiro benefits. If you have a genuine WC injury then you need to stay within the framework of the WC system. In that, if you disagree with the determination of their Utilization Review opinion you are able to request a Panel Qualified Medical evaluation. Mixing up the different carriers just to get something paid for will not work out nicely and you'll likely be caught in the middle with the bill very frustrated. Remember you can call the information & assistance officer too. they're a huge help if you can't have a meaningful conversation with the claims adjuster for the WC carrier.