How Long Can my Adjuster Wait to Authorize Medical Care?
Here at Harris Guidi Rosner, P.A., a new client often asks us “How long can my adjuster wait to authorize medical care?” This is one of the most important and frequent questions we are asked in our workers’ compensation department.
The timeline an adjuster should respond to a request to authorize medical care when the request is made in writing from an authorized treating workers’ compensation doctor, is called the “Three and Ten-Day Rule. ” Florida law says that when an adjuster gets a request for authorization from an authorized doctor, the adjuster has three (3 – business) days to respond to the doctor by phone or writing. If the request is for surgery, a specialist referral, or testing costing more than $1,000, the adjuster has ten (10 – calendar) days to respond. If the adjuster does not, the adjuster waives his or her right to argue that the requests are not medically necessary.
The adjuster is required under this rule to respond in some fashion to the doctor that the carrier is investigating the request or authorizing it.
Authorize Medical Care – the Florida Statutes
The relevant Florida statute to authorize medical care is below:
440.13(3)(d) A carrier must respond, by telephone or in writing, to a request for authorization from an authorized health care provider by the close of the third business day after receipt of the request. A carrier who fails to respond to a written request for authorization for referral for medical treatment by the close of the third business day after receipt of the request consents to the medical necessity for such treatment. All such requests must be made to the carrier. Notice to the carrier does not include notice to the employer.
(i) Notwithstanding paragraph (d), a claim for specialist consultations, surgical operations, physiotherapeutic or occupational therapy procedures, X-ray examinations, or special diagnostic laboratory tests that cost more than $1,000 and other specialty services that the department identifies by rule is not valid and reimbursable unless the services have been expressly authorized by the carrier, unless the carrier has failed to respond within 10 days to a written request for authorization, or unless emergency care is required. The insurer shall authorize such consultation or procedure unless the health care provider or facility is not authorized, unless such treatment is not in accordance with practice parameters and protocols of treatment established in this chapter, or unless a judge of compensation claims has determined that the consultation or procedure is not medically necessary, not in accordance with the practice parameters and protocols of treatment established in this chapter, or otherwise not compensable under this chapter. Authorization of a treatment plan does not constitute express authorization for purposes of this section, except to the extent the carrier provides otherwise in its authorization procedures. This paragraph does not limit the carrier’s obligation to identify and disallow overutilization or billing errors.
If you need assistance getting your medical benefits addressed and authorized the Jacksonville Workers’ Compensation attorneys at Harris Guidi Rosner, P.A. are here to help. Call us at (909) 777-7777 for a free consultation to talk about your work accident and how we can assist you or email us at mills@harrisguidi.com to schedule a free consultation.
