# Workers Comp denials



## lorig (Feb 7, 2013)

I'm trying to get payment on a claim for a patient with knee pain. The doctor feels the pain is due to a previous ankle surgery that was performed because of a Workers Comp injury. Workers Comp is refusing to pay.  How do I get this paid?


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## airart (Feb 8, 2013)

*WC Insurance Re-opening Possibility for original injury?*

The employee should see about doing a re-opening on his worker's compensation claim.  Depending on the state will depend on the time frames this can be done.  Here is an article on steps to follow about seeing this done.

Reopening Your Workers' Compensation Claim
By Virginia Hunt 

1. Know the reopening rules specific to your claim in your state 
Only if you received temporary total disability benefits because you were off work due to your injury for more than five days, or if you received a permanent partial disability award are you entitled to lifetime reopening rights on your Nevada workers' compensation claim. If you had a serious injury, but were not off work for five days, or did not get an impairment award, you probably are limited to reopening within a year of the date your claim was closed. If your had a minor injury involving minimal medical costs, you may not have any reopening rights.

2. Get the date your claim was closed from the adjuster 
The law makes it more difficult to reopen a claim within a year after a claim is closed if a permanent partial disability award was paid. You should probably wait until a year after claim closure to submit a reopening request.

3. First get a doctor's report that shows your injury has worsened.  You must pay for an exam and a report from a doctor who can document that your work injury has worsened from the time your claim was closed. It is best to give the examining doctor a copy of the rating evaluation report that was used to close your claim and award you a settlement so that the doctor can discuss how your injury has worsened. It is a good idea to try to have the doctor who treated you when the claim was open examine you and discuss how your injury has worsened and why the claim should be reopened.

4. Make sure that the examining doctor discusses a need for more treatment 
If the doctor only states that you need a MRI or some other diagnostic evaluation before he can determine what treatment is necessary, the insurer is not going to reopen your claim. Unfortunately, you must first pay for the recommended MRI or x-rays so that the examining doctor can specifically state what treatment is necessary. When you have a report that states that the injury has worsened, and that you need more treatment, then attach it to a letter to the insurer, with your old claim number, and request that your claim be reopened.

5. Pursue any denial through the appeals process.  Insurers don't like to reopen closed claims, so be prepared to have to appeal any denials. Don't bother trying to reopen your closed claim unless you need serious medical treatment consisting of additional invasive medical procedures like surgery or epidural injections. The insurers will not reopen to pay for more pain medication or to give you six more physical therapy visits. If your request is denied, make sure that you file a timely appeal, because you cannot make another request to reopen your claim for a year if your previous request is denied.

Article Source: http://EzineArticles.com/4103396

Varies by state so contact your department of Insurance on time frames and guidelines.  

Scenarios:
Under the Worker's Compensation system, if compensation for permanent impairment of one part of the body leads to the development of symptoms in other parts of the body, you should have a right to reopen the claim for the new condition. It is largely a medical question as to what brought about the arthritis in your left hip. If your doctor believes that it is related to the change in gait, stance or weight bearing, then you should file a reopening application. If the reopening application is denied, please see an attorney.
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if your industrially related knee condition has worsened objectively, you should be entitled to have your claim reopened and have a re-evaluation of the permanent partial disability decision made. As the law now stands, an individual has seven years from the date that the claim is first “finally closed” to reopen the claim. If you wait beyond seven years from the first final closure of your claim, you may lose the right to reopen the claim.
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Washington State Guidelines for Workers Compensation.


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## mitchellde (Feb 9, 2013)

I would add to this that when you code the diagnosis use the pain code 338.xx with the knee pain 719.46 with the appropriate late effect code 905-908 and look in the E code section to see if there is a late effect of accident code for the industry accident.  Allow your dx codes to help tell the story as well.
This will be so much easier with ICD-10 CM codes!


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## davetsn (Feb 10, 2013)

*Worker's comp*

See if the ankle surgery claim is still open. Call the insurance company that handled the worker's comp to see if they have closed it. If not, bill it to the worker's comp insurance. If it is closed, you may have to appeal to re-open the worker's comp claim if your doctor is for sure certain it was the surgery and nothing else. I am not sure why the insurance company would deny because it is a different part of the body.


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## lorig (Feb 13, 2013)

Thank you all so much for your thoughtful answers.  I appreciate your responses and look forward to getting this paid.


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