Who Pays for Medical Treatment in Georgia Workers' Comp Cases?

In Georgia workers’ compensation cases, an employer’s insurance company pays for an injured worker’s approved medical treatment. Those workers’ compensation benefits should cover reasonable and necessary medical expenses, including doctor visits, surgery, therapy, prescriptions, and medical equipment. If the injured worker needs emergency care, the insurer may still pay if the treatment was necessary.

If you suffer an on-the-job injury, you should not pay the cost of your medical care if you follow the rules, such as choosing an authorized treating physician or managed care organization. An experienced workers’ compensation attorney at R. Alan Cleveland, LLC, can review your case and help you understand the medical benefits you are due.

Will Georgia Workers’ Comp Cover All Your Medical Bills?

The employer’s workers’ compensation insurer covers authorized medical treatment in Georgia workers’ compensation cases. Your employer must pay for care that a licensed doctor orders, including doctor visits, surgeries, hospital stays, therapy, prescriptions, and medical equipment. You shouldn’t have to pay hospital bills or any other out-of-pocket expenses for approved medical services.

However, the coverage is not unlimited. If your injury isn’t “catastrophic” under Georgia workers’ compensation law, medical benefits will stop after 400 weeks (about 7.5 years). If the work injury is catastrophic, you can get lifetime medical coverage. 

Catastrophic injuries include:

• Spinal cord injuries that result in paralysis of a limb or the trunk
• Amputation of an arm, hand, foot, or leg,
• Severe brain injuries accompanied by sensory, motor, or communication disturbances
• Second- or third-degree burns covering more than 25 percent of the body.

What If You Need Immediate Emergency Medical Treatment for Your Injury?

If you suffer a serious injury at work and need emergency medical care right away, don’t wait for permission. The State Board of Workers’ Compensation can order your employer to pay for your emergency treatment, as long as it was necessary and related to your injury. To support your claim, keep copies of your medical records and bills.

If the insurance company denies coverage, you have the right to request a hearing and fight for your benefits. You’ll need the help of a skilled attorney who can file your workers’ comp claim and guide you through the process of seeking the benefits you deserve.

After the emergency passes, you must follow the regular workers’ compensation process. You may need to switch to a doctor from your employer’s posted panel of physicians or a certified managed care organization. If you continue seeing a provider outside the approved network without permission, the workers’ comp insurer may stop paying your bills.

Do You Have to Use a Specific Workers’ Compensation Doctor for Your Work-Related Injuries?

Georgia law requires you to see an approved doctor for your work-related injury. Your employer must post a list of at least six doctors, called a “panel of physicians,” in a visible location at work. You must choose your treating doctor from this list unless your employer uses a certified managed care organization (MCO). In that case, you must follow the MCO’s process to select your provider.

You can change your doctor once without permission if the new doctor is on the panel or part of the approved network. Any additional switches require approval from the State Board of Workers’ Compensation.

If you go to a doctor who isn’t on the panel or part of the MCO without approval, workers’ comp may not cover the treatment. Always check that your doctor is on the panel before scheduling care. If your employer hasn’t posted a panel or MCO information, you may have more freedom to choose a doctor.

When Could Your Workers’ Comp Medical Coverage Be Denied?

A workers’ compensation insurer will rarely approve every medical request, even if your injury happened on the job. Several common issues can lead to a denied claim, especially when the treatment doesn’t follow approved guidelines or when the insurer raises questions about necessity. Consider the following situations:

• Surgery – An insurer will closely review any request for surgery, particularly when the surgery is significantly more costly than other options. The prescribing doctor must explain why the surgery is necessary. If not, the workers’ comp insurer may deny coverage. You may also have difficulty getting approval and payment if the surgery is expensive, and there is no clear evidence that it will aid your recovery.
• New and/or experimental treatments unsupported by significant research – A workers’ comp insurer may also reject new or experimental treatments. The insurer may argue that the treatment lacks strong research support or falls outside standard medical care. They could also argue that it’s not reasonable or necessary.
• Specialized treatment ordered by a non-specialist medical provider – Specialized care needs to come from a qualified specialist. If a general physician orders advanced treatment, such as pain management or neurological tests and procedures, without proper training or referral, the insurer may deny payment.
• Extensive diagnostics – Extensive diagnostic tests can also get flagged for denial if the insurer believes they are unrelated to your work injury. The insurer may deny coverage for MRIs, CT scans, or nerve studies if the doctor provides insufficient justification for the order.
• Duplicate treatments ordered by more than one doctor – If multiple doctors order similar tests, the insurer may approve only one and deny the rest as duplicates.

What Can You Do If Your Medical Treatment Claim Gets Denied?

You don’t have to accept a denial of your medical treatment by the workers’ comp insurer. You can challenge the denial through the State Board of Workers’ Compensation. Here are the steps you can take: 

• Review the denial letter, which should explain why the insurer denied your treatment.
• Talk to your authorized treating doctor. Ask them to provide more details or updated records to support your request. Sometimes, a stronger explanation from your doctor can help reverse the decision.
• If that doesn’t work, you can file a WC-14 form to request a hearing. A workers’ comp judge will review your case and decide whether to approve the treatment.
• You can also request mediation to try to resolve the issue without a formal hearing.

This process is complicated. Don’t go through it alone. You can hire a workers’ compensation lawyer to guide you and protect your right to medical care.

Contact a Georgia Workers’ Compensation Lawyer Today

If you have questions about your workers’ comp medical benefits, don’t wait to get answers. Contact R. Alan Cleveland, LLC today for a free consultation. We’ve secured more than $150 million for our clients, and we’re ready to help you, too. We’ll explain your rights and help you take the next step.

Visit Our Georgia Workers’ Compensation Law Offices