How Does Workers’ Compensation Medical Pre-Approval Work in Pennsylvania?

When an employee in Pennsylvania is injured on the job, they are entitled to workers’ compensation benefits. These typically include medical treatment, wage replacement, and rehabilitation services. However, navigating medical care through the workers’ compensation system can be confusing. One key concept to understand is medical pre-approval.

Medical pre-approval ensures that certain treatments or procedures are authorized before the injured worker receives them. This helps guarantee that the workers’ compensation insurance will cover the cost. For injured workers already dealing with pain and uncertainty, delays in treatment can be overwhelming. In this blog, we’ll explain how medical pre-approval works in Pennsylvania workers’ comp cases and what to do if treatment is denied.

What Is Medical Pre-Approval in Workers’ Comp?

Medical pre-approval refers to a process where the insurance company reviews a proposed treatment plan and decides whether to authorize it. It’s typically initiated by the medical provider, who seeks confirmation that they’ll be paid for their services. Pre-approval ensures that treatment is reasonable, necessary, and directly related to the work injury. It also protects the provider from performing care they won’t be reimbursed for.

The Pre-Approval Process in Pennsylvania

Unlike some states, Pennsylvania law does not require pre-authorization of medical treatment. The Pennsylvania Workers’ Compensation Act allows treatment without formal pre-approval. Unfortunately, this leaves medical providers hesitant to treat without a payment guarantee, which can delay care for the injured worker.

What Happens if Treatment Is Denied?

Even though pre-approval isn’t required, there are steps injured workers can take when facing a denial:

• Attorney Intervention: Your workers’ compensation attorney can speak with the insurance company or medical provider to help reach an agreement. Sometimes, a provider’s explanation of medical necessity can lead to approval.
• Alternative Providers: If the insurer remains uncooperative, your attorney may refer you to a different provider for the same treatment, especially for routine care like MRIs or steroid injections.
• Utilization Review: You may also request a prospective utilization review to formally challenge the denial. This is often the most effective way to prove treatment is medically necessary.

What Is a Utilization Review?

A utilization review (UR) is a formal process where the Workers’ Compensation Bureau reviews whether a proposed treatment is reasonable and necessary. A UR can be filed by the employer, insurance carrier, or the injured worker.

Once filed, the Bureau assigns the case to a Utilization Review Organization (URO). The URO gathers medical records and submits them to a reviewer—a licensed medical provider with similar qualifications—who will assess the necessity of the proposed treatment. Injured workers can also submit a personal statement in support of their care.

The process typically takes about 65 days. If the reviewer determines the treatment is necessary, the insurer must pay for it. If not, you have the right to appeal the decision before a workers’ compensation judge.

Final Thoughts

Medical pre-approval is not required under Pennsylvania law, but that doesn’t mean you’re out of options if your care is denied. From facilitating communication with providers to filing a utilization review, our team at Stern & Cohen is here to help.

If you’ve been injured at work and are struggling to get the treatment you need, contact us today. We’ll help you understand your rights, navigate the process, and fight for the care you deserve.