How Long Does Workers’ Compensation Pre-Authorization Take?

Injured workers can sometimes wait weeks while their doctor’s office tries to get certain treatments pre-authorized. This delays recovery and is also unnecessary because Vermont does not require pre-authorization in workers’ compensation claims.

In this post, our attorneys share some key points about pre-authorization. 

The bottom line is: In Vermont, you do not need pre-authorization to get reasonable and necessary treatment for a work injury. But if your doctor requires pre-authorization because they want to make certain they will be paid, there is a procedure they can follow to get this assurance. If they request preauthorization in writing, 14 days is the maximum time that you should have to wait for a response.

Pre-Authorization Is Not Required

Doctors sometimes believe that pre-authorization is necessary for them to get paid, but this is incorrect. If you have an approved Vermont workers’ compensation claim, your doctor can treat you and bill the workers’ compensation insurance company for payment. The insurance company must pay within 30 days. Treatment must be reasonable, necessary, and related to your injury,

How Long Does Pre-Authorization Take?

If your doctor requests pre-authorization, Vermont has specific steps and timelines that direct how workers’ compensation insurance companies must respond. After the insurer gets the request, they have 14 days to respond. Their response could be to accept the request, deny the request, schedule you to attend an independent medical examination (IME), or ask to review your medical records. Requesting the IME or the records review will extend the time period to 45 days after they receive the request.

What Do Medical Providers Need To Do?

If your doctor decides to request pre-authorization because they want peace of mind about payment, the most important thing they can do is fill out the request correctly. An incorrect request is easy for the insurance company to deny. 

Four important steps for your doctor's office to follow are:

1. Make the request in writing. Calling and leaving a voicemail with the adjuster will not work. All the required forms are available on our medical resources page.
2. Include medical evidence to support the proposed treatment, such as medical visit notes or the doctor’s referral for the treatment.
3. State (in writing) that the treatment is reasonable, necessary, and related to the work injury.
4. Give some basis for the doctor’s opinion that the proposed treatment is a good idea.

What Happens If You Get A Denial Or No Response?

The insurance company can deny a pre-authorization request, delay it by requesting an IME or records review, or fail to respond within the 14-day window. In any of these situations, you can get the Vermont Department of Labor (DOL) involved, and they can order the insurer to pay. An experienced workers’ compensation lawyer can help you get DOL to order the insurance company to authorize the treatment. DOL will make the order if your doctor did the pre-authorization request correctly and the requested treatment is reasonable and necessary. If the insurer ignores the request, DOL must order payment.

Next Steps

Once you have made the difficult decision to go ahead with an important procedure, such as surgery or testing, it’s better for your recovery and your peace of mind if it happens as soon as possible. Knowing that you don’t have to sit around waiting for pre-authorization is beneficial for you and your family. If you are experiencing problems with pre-authorization, there are three things you can do:

1. Let your doctor’s office know that pre-authorization is not required for workers’ compensation treatment in Vermont.
2. Help your doctor’s office request pre-authorization properly. Delays happen when medical offices don’t follow the correct procedure. If BFS represents you, ask your attorney for our Pre-authorization Procedure Card that explains the steps for pre-authorization. You can keep it in your wallet and show your doctor’s office when needed.
3. Because educating your doctor about pre-authorization while you are trying to heal shouldn’t be your responsibility, talk to an experienced workers’ compensation lawyer who can take that burden off your shoulders. We talk with medical staff about pre-authorization all the time. Our paralegals sometimes even fill out the pre-authorization paperwork for them to sign, and then we send it to the insurer ourselves. This lets us track the request from start to finish, making sure it gets done as fast as possible.

Biggam Fox Skinner offers a free consultation about your case with no obligation to hire us. Call us today at 802-455-9141. You can also contact us through email or chat with us using the Chat feature on this page.