Workers' Compensation

The doctor has ordered a test but the adjuster isn’t approving it. Why?

There’s no simple answer to this but here are a few possibilities. First, she’s lazy or procrastinating or overworked. Maybe.

Second, she’s in denial that the test is actually necessary. She may be hoping that you spontaneously get better without the test. That occasionally happens but not often. Most experienced workers’ compensation doctors aren’t just ordering tests randomly. They don’t order tests they don’t think are necessary. But some adjusters act like they know more about modern medicine than someone who went to medical school.

Third, she may have an internal review that has to be done before the tests can be authorized. Some insurance companies have an internal “utilization review” performed by an in-house “doctor” to second guess the doctor who ordered the tests.

Fourth, the adjuster may be trying to line up a second opinion with another doctor who may say the test isn’t necessary. You may ask yourself: would an adjuster really pay an extra month of weekly benefits, pay hundreds of dollars to a rehabilitation nurse to set up a second opinion, and pay hundreds more outside of the Industrial Commission medical fee guidelines, just in the hope of avoiding a $750 test? The answer is yes.