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who gives the final approval for surgery?

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  • who gives the final approval for surgery?

    Could someone tell me who actually approves surgery in a w/c case? I am going on Tuesday to the neurosurgeon who I want to operate on me, and want to schedule it that day, will there be a big long delay with w/c on this, anyone know? Their IME doctor suggested surgery if conservative methods didnt help, they didnt. Or will w/c drag this out?

  • #2
    The carrier approves surgery, or more accurately, the adjuster on your claim. I have no idea whether there will be a delay but in your case, I'd be surprised if there was. Typically authorization takes just a day or two in a case like yours. Often, the surgeon will allow you to schedule the procedure, then allow you to get the authorization in the meantime.
    I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

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    • #3
      The good news is that since medical treatment can not be apportioned, if your injury is a contribuing factor to your need for surgery, they pay for it. Given what you have said in your other posts, I doubt you will have problems now.
      I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

      Comment


      • #4
        Rearended, I was just approved this past week for my shoulder surgery. The ATP determined on Aug 20 that this surgery was necessary after all conservative measures had been exhausted through out the past 5 months.

        The approval for my surgery was made through a managed care pre-authorizations services firm the WC IC uses. It is not the same company as the WC IC in fact they aren't even in the same state. My WC IC is in LA and the MCPAS is in CA. My claims adjuster sent in over 70 pages of documentation to them as well as what the physicians assistant sent. It took well over a month to get the approval. Sure hope yours gets approved in a much shorter time than mine was. The good news, I am scheduled this coming Thursday to finally get the repair work done.

        KM
        Last edited by Kick Me; 10-01-2007, 12:30 AM.
        Information posted by me is my "OPINION". I do NOT give legal advice to anyone as like most here I am NOT an attorney.

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        • #5
          Originally posted by joec
          The surgeon.
          JoeC
          Good answer JoeC and so many ways you are correct. That is exactly WHO SHOULD get to make the call. It just isn't the way it works in the real world.

          Unfortunately the WC IC or a contract company they use will have the final yea or nay that really counts. Just went through it. Surgeon says do it over 6 weeks ago but would not schedule me until the IC OKed not only the surgery but the payment for it. Guess even my renowned surgeon doesn't want to work for free, LOL.

          Rear Ended for your sake I too hope ElleMD is right in her estimate of how long it will take to get approval. I expected mine to only be a day or two. My CA had told me several weeks in advance that she would OK the surgery once the doc gave the go ahead. Unfortunately it wasn't up to her to OK or deny. It was, as I posted yesterday, a managed care pre-authorization company 2,000 miles away. Now FINALLY over 7 weeks later I will be having the procedures this Thursday.

          I am MORE than anxious to get back to work. This has been just about the worst 6 months in my life. I would have already gone back to work if my doctors would have allowed me to. With the kind of injury I have I would be a true hazard for many people to go back to work in this condition. Just wouldn't be safe for me or anyone else.

          Best of luck to you Rearended when you go under that knife. Hope they are able to fix you up good as new and that your recovery goes smoothly.

          Take Care and Be Well,

          KM
          Last edited by Kick Me; 10-01-2007, 08:49 PM.
          Information posted by me is my "OPINION". I do NOT give legal advice to anyone as like most here I am NOT an attorney.

          Comment


          • #6
            Since the adjuster or at least someone at the carrier has been authorizing treatment directly to this point, I would not expect them to suddenly outsource this function now. We do use an adminstrator for care coordination when surgery or major treatment is necessary, but they do not approve anything besides the bill (essentially they reprice it in line with the MD Fee Schedule) and assign a NCM who assists in making the appointments. It can take a few weeks to get an appointment for surgery and do the pre-surgical work up, but that isn't a function of WC. Where I am you actually can get in sooner if it is WC than if it is not. I had two employees with the same basic injury in the same week- a torn meniscus. One was WC one was not. The WC claim was into an ortho the next day and had surgery a week later. The non-work related one treated at the same practice but was not even able to get an appointment with the ortho until 9/10, when the injury occurred on 8/14.

            A month to get surgery authorized is to me unacceptable. I'm not sure how your claims are managed but I'd have been on the phone with the carrier or care coordinator asking some questions as the employer. It doesn't help my goal of getting the employee the care they need and getting them back to work to have them sitting home for more than a month waiting on an authorization if it is a forgone conclusion.
            I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

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            • #7
              Originally posted by ElleMD View Post

              A month to get surgery authorized is to me unacceptable. I'm not sure how your claims are managed but I'd have been on the phone with the carrier or care coordinator asking some questions as the employer. It doesn't help my goal of getting the employee the care they need and getting them back to work to have them sitting home for more than a month waiting on an authorization if it is a forgone conclusion.

              This I agree with 100%. You get no quibble out of me about it. I found it to be perfectly ridiculous to be hung out to dry for so long. In reality it was known by month 3 that the shoulder surgery was going to have to be done. Due to also having a cervical spine injury everything was brought to a halt until a cervical MRI and emg was done. You guesses it nearly a month wait for each one. Total Toro pucky IMHO. Had they went on and done the shoulder surgery when it was first determined to be needed I would be back to work by now. The cervical injury is actually an aggravation of a preexisting and is not operable at this point so I am learning how to deal with the exacerbation of the pain. I will certainly be glad when it is Friday this week. For it will mean Thursday finally got here, (day my surgery is scheduled), and I will be on the other side of the hill. The down hill side, Thank God.

              KM
              Information posted by me is my "OPINION". I do NOT give legal advice to anyone as like most here I am NOT an attorney.

              Comment


              • #8
                If there were cervical issues then yes, getting the MRI and EMG would be smart. Skipping those steps would be borderline malpractice. I can't speak to your region but around here you are looking at a month or so for an appointment for either unless it is an emergency. That doesn't have anything to do with care being authorized but rather the lack of facilities and the demand for services.
                I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

                Comment

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