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Authorization of Medical Care in Florida Workers’ Compensation Claims

Authorization of Medical Care in Florida Workers’ Compensation Claims

Florida workers’ compensation claims involve a process where medical treatment is authorized for an injured worker. In most situations, the authorized physician will make recommendations for testing or medical treatment. Generally, the recommendation is sent to the adjuster/insurance company requesting authorization.

Authorization of Medical Care in Florida Workers’ Compensation ClaimsThe adjuster will then approve or deny the request.

Sometimes, this process, which seems straight forward, can be complicated. As an example, the following scenarios case play out (this is not an exhaustive list):

  • There can be extreme delays, and lack of communication. In other words, just NO response.
  • The insurance company suggests another medical service in place of what was recommended.
  • The request can be sent to Utilization Review and then either approved or denied – this is sometimes called “certified” or “non-certified”.
  • The adjuster states the medical care is authorized, but the provider does not have the approval/authorization.
  • The insurance company states that workers’ compensation does not cover what is recommended. This can come about with newer types of treatments, such as stem cell treatments/injections.

If there are delays of denials of the authorization of medical care, AN INJURED WORKER HAS RIGHTS – delays and denials can be challenged through the filing of a petition for benefits.

The Florida Workers’ Compensation Act does have strict time deadlines for a response to the physician. For example, F.S. 440.13(3)(d) and (i) sets forth three and 10 day deadlines for a response, depending on the medical service recommended, and failure to respond prevents the insurance company from challenging the medical necessity of the recommended treatment/service. This issue typically comes to light in the litigation/discovery process during a dispute through the court.

It is the Claimant’s burden to prove all elements of his claim and to prove entitlement to any claimed benefit. Bob Wilson Didge v. Mohammed, 692 So. 2d 287 (Fla. 1st DCA 1997); Fitzgerald v. Osceola Cnty. Sch. Bd., 974 So. 2d 1161 (Fla. 1st DCA 2008). It is not the E/C’s burden to prove Claimant is not entitled to the benefits claimed. Mitchell v. XO Comm’ns, 996 So. 2d 489 (Fla. 1st DCA 2007).

If you have questions regarding the Authorization of Medical Care in Florida Workers’ Compensation Claims, feel free to contact our office for a free consultation. It is important that an injured worker learn his or her rights, as the insurance company’s delay or denial can be challenged.