At the SAWCA Annual Conference, a panel discussed delays in the workers’ compensation system. The panel was:
- Shannon Bruno Bishop – Administrative Law Judge, State of Louisiana
- William Underwood – Attorney – Albany, GA
- Ryan Brannan – Commissioner – Texas Department of Insurance, Division of Workers’ Compensation
- David Havlicek – Attorney – Orlando, FL
- Frank McKay – Chair – Georgia Workers’ Compensation Board
On the medical side, there are frequently delays in areas such as changing treating physicians and major surgeries. However, delays are also seen in authorizing more basic treatment such as physical therapy. There are not usually delays in getting the initial treatment but referrals to specialists also commonly leads to delays. There are many reasons for the treatment authorization delays including the utilization review process or lack of timely response from the adjuster. Incomplete information from the physician’s office also results in delays because the adjuster lacks the necessary information to complete utilization review and authorize the care.
There are significant variations in the states regarding how they ensure timely authorization for medical care:
- In states with strong treatment guidelines, there should be less delay in authorizing medical treatment because the physicians know exactly what treatments are allowed under the guidelines. Texas is such a state, and adjusters have a 3 day window to authorize care or it is presumed authorized if it follows the guidelines. Texas also has administrative penalties if payers do not respond within the 3 day window.
- In Louisiana, if treatment is not authorized within the prescribed period of time it is presumed denied. They also lack the administrative penalties to encourage timely response. Louisiana has recently developed treatment guidelines but these are currently being challenged in the courts.
- In Florida, if payers do not authorize treatment timely they lose the right to later dispute that the treatment was medically necessary. There are no administrative penalties for not responding timely.
In states with treatment guidelines or a state administered medical review process, the medical director employed by the division of workers’ compensation plays a significant part in these processes. The regulators attending talked about the challenges associated with keeping their medical director position filled. They indicated there is high turnover with that position as the physicians get tired of dealing with the workers’ compensation bureaucracy.
From the time a hearing is requested until a hearing is actually held leads to significant delays in the system. Usually hearings are reset several times before it is actually held. Most of these continuances are mutually agreed upon as parties work through the discovery process. Once the hearing is held it takes weeks to months for a decision to actually be issued by the judge. If a claim goes through an appeals process it usually takes several years for this process.
Some states allow for expedited hearings under certain conditions. Medical treatment authorization disputes are often times expedited in order to facilitate timely care for the injured worker.
Certain states require mandatory mediation in an attempt to expedite the dispute resolution process. Whether or not this process actually works is the subject of debate. Some feel this just delays getting issues to a hearing as the parties do not mediate with a goal toward resolution.
In Texas, medical disputes are adjudicated through a different process where physicians are making the determinations based on the treatment guidelines rather than having judges rule on these disputes. There are very few states that have such a medical review process.