Sometimes workers’ compensation cases have diagnostic or therapeutic challenges. In those cases, attending providers are allowed to arrange most consultations with specialists without obtaining prior authorization.

 

Treatments that do not require authorization

It’s true! But, for some reason both injured workers and treatment providers rarely believe me. Don’t take my word for it. Here is what L&I says about it: https://lni.wa.gov/patient-care/authorizations-referrals/authorization/retrospective-authorization. There are only two exceptions to this rule:

(1) mental health evaluations require prior authorization; and

(2) Independent Medical Examinations (IMEs) can only be arranged by the Department of Labor and Industries (L&I) or Third-Party Administrator.

That leaves the door open for many kinds of consultations to happen without prior authorization.

In fact, there are many treatments that do not require pre-authorization. Every year L&I publishes an updated fee scheduled and payment policy (MARFS) excel sheet. These sheets contain a column identifying whether an item requires pre-authorization. Did you know most items do not require pre-authorization? While surprising, it is a terrific benefit for injured workers!

 

More information and conclusions

L&I wants to keep claims moving forward. There’s no doubt about it. That means there is less red tape for making referrals and providing treatment than providers and injured workers often realize. If a claim is presenting challenges, so long as the referral is not for an IME or mental health evaluation, providers should feel empowered to arrange the referrals they feel are appropriate. If treatment providers are reluctant to schedule consultative appointments, injured workers should feel empowered to tell providers that pre-authorization is not required.

 

For more information, the L&I website contains lots of information regarding treatment authorizations and referrals.