Denied Care Because ‘It’s Not Authorized’: How to Document Medical Necessity under Colorado’s Rule 16 Utilization Standards
You may have difficulty with the insurance company at various points of the workers’ compensation claims process. The Lakewood workers’ compensation lawyers at The Frickey Law Firm can help you navigate these challenges.
Even if you had to fight to have your workers’ compensation claim approved by the insurance company, it may be far from the end of your battles. Insurance companies often try to evade their legal obligations to cover the reasonable and necessary medical care associated with your work injury. You may be shocked and angered to learn that the care that you need has been denied by the insurance company because “it is not authorized.” Know that you are not powerless under Colorado law, and you can take steps to fight back with a well-documented appeal.
The most effective workers’ compensation claimant is one who is informed about their legal rights. Speak to the Lakewood workers’ compensation attorneys at The Frickey Law Firm by calling us at 303-237-7373 to learn more about how you can proceed in your case.
Rule 16 Plays a Key Role in Your Lakewood Workers’ Compensation Case
When it comes to getting medical care for your work-related injury, Colorado’s Rule 16 is an extremely important thing to understand. Rule 16 applies when there are disputes over an injured worker’s medical condition. Whether medical treatment is reasonable and necessary is one key issue that is addressed by the rule.
Insurance companies are always looking out for their bottom line. Even if they have an obligation to pay for your care, they may not approve everything that your treatment provider recommends. The insurance company does not always have the final say in approving your care. You have the ability and right to appeal any care denial, and you will receive a binding decision from an objective administrative law judge, as opposed to an insurance company with a financial motive.
How to Provide Effective Rule 16 Evidence to a Workers’ Compensation Judge
The key thing that you will need to do is provide documentation to this judge, who can make a decision about whether specific care is a medical necessity. The judge will need a legal record in front of them when they hold a hearing or attempt to adjudicate a dispute. Working with an experienced workers’ compensation attorney in Colorado, you can build the record that is necessary to persuade a judge to overrule an insurance company’s determination.
A medical opinion is one of the most crucial aspects of a Rule 16 record that could persuade a judge to agree with your position. Here, the Colorado Division of Workers’ Compensation has ordered a medical review and assigned an independent physician to your case. They will conduct an examination and write a report that contains their recommendation to the judge. Although a judge is not bound to rule in accordance with this opinion, it can carry a large amount of weight in their decision.
What You Must Provide to the Rule 16 Physician
To prove your case, there is much more involved than just showing up at an examination and communicating with the assigned Rule 16 physician. You must submit a detailed file to them for their consideration that contains your strongest evidence that proves your position. At the outset, you must provide your medical history as it relates to your work-related injury. This can include:
- The medical diagnosis of your condition
- Treatment records that show that you have consistently sought medical attention and followed all recommendations
- Imaging and test results that evidence your condition
- Copies of your communications with medical providers about your condition and appointments
Once you have the Rule 16 file, it is not the end of your case. Even if the report is in your favor, you should present additional evidence in your favor, such as an opinion of a medical expert about the necessity of your care. Certainly, if the Rule 16 physician has not agreed with your position, you must have additional evidence that proves your side of the story, given that the judge may be inclined to side with the opinion that they already have at their fingertips.
The best way to build a compelling case that includes persuasive documentation is to get legal help from an experienced Colorado workers’ compensation attorney. Your lawyer has the experience to know what an administrative law judge may be looking for and how to present well-supported arguments that could persuade them to rule in your favor.
Contact a Lakewood Workers’ Compensation Law Firm
Do not let the insurance company get away with protecting its own profits at your expense. Get legal help from an experienced workers’ compensation lawyer in Colorado at The Frickey Law Firm because the insurance company may get the better of you if you proceed on your own. Schedule a free initial consultation by filling out an online contact form or by calling us today at 303-237-7373.
Adam M. McClure was recently selected for membership in “The National Trial Lawyers: Top 40 Under 40” organization, making him one of only 40 Colorado lawyers to be awarded this honor. Mr. McClure is an exceptional litigator. He has been a key member of The Frickey Law Firm since 2003. Learn more here.