Workers Comp Audit Stress Reducer
Use It For Your Next Premium Audit

Workers Comp Medical Authorizations – Too Slow?


Workers Comp Medical Authorizations – Adjusters’ Bane Part 2

One of the tasks that claim departments have struggled with over the years starts with a phone call from a medical provider.  Workers Comp medical authorizations have become more complicated as the medical sciences have advanced in leaps over the last few decades.

Lagging FROIs

Some of the blame can be placed externally with the insured employers filing first reports of injury (FROIs) late.  Late FROIs, measured as lag time, can easily start a process where the claims department reaches critical mass.

I had written on and coined the two terms zombie phone calls and twilight zone phone calls.  This situation occurs when medical providers of any type call into a claims department and requests workers comp medical authorizations to guarantee payment for their services.  If the adjuster has not seen the FROI, then they cannot authorize anything.  This frustrates the adjuster and medical provider.

pic of shattered phone - workers comp medical authorizations
Wikimedia Use License – Ashwin Kumar, Bangalore India

Workers Comp Medical Authorizations Lost In Shuffle

Sometimes claim departments can lose a med auth request in a large number of incoming calls and emails during their workday.   That remains a reality – not an excuse.   Some workers comp medical authorizations have to “cross many desks” if the medical treatment is estimated to be over a certain amount.

When J&L performs loss run, reserve, or claim reviews, we see that this remains a struggle at certain TPAs and carriers.  The claims that have rehab nurses/field case managers usually do not have the same concern as the rehab nurse is can filter the workers comp medical authorizations more expediently.

Fixing Authorizations – American Medical Association

I was reading a Business Insurance (free and paid subscriptions – worth it)  article that pointed that linked to a website known as fixpriorauth.org.

The website conducted a survey of medical providers that contained shocking numbers.  The AMA created a website (see above link) due to this concern.   The Fix Prior Auth website does not single out any line of insurance.    Let us look at a few stats from the survey  – (PA = Prior Authorization Delay)

  • 30% of physicians surveyed said that PAs caused a serious adverse event for their patients
  •  79% of treating physicians reported treatment abandonment due to PAs
  • 94% of physicians experienced treatment delays due to PAs

The above link also contains an Employers Toolkit that can be downloaded – and should be – to examine a few aspects when an insured is searching for or renewing their policy or TPA agreement.   TPA and carrier claim departments should also download it as an idea generator on how to facilitate the authorization process.

I know this study was not directed specifically at workers comp – but health is health even in WC claims. For the AMA to create a subsite just to address the issue shows the importance of fixing workers comp medical authorizations.

Also Read: What Is A Guaranteed Cost Program In Workers Compensation?


2 Responses

  1. The reason for the issues are because there are not enough workers comp adjusters. Is it because we had many leave the industry? I believe even though they may have left companies/carriers/TPAs want to see how far the can push adjusters to keep their jobs. It’s a nightmare. I recently was handed 280 lost time claims. It was my worst nightmare in all the years I’ve been in the industry. They wanted me to literally work 15 or 16 hour days because if I didn’t I would be put in termination notice. I gave up and almost on the industry. But I received a call regarding a desk with large losses, cat and heavy litigated cases but only 90 claims. Finally I can get back to the Career I love., managing a claim the way it’s meant to be done. People need to take a stand. The employees and employers are suffering not to mention the adjusters. It’s disgusting what they are making us do. I had no life.

  2. Wendy, thanks for commenting on the article. I agree that some adjusters are overloaded. I am glad that you found another job to your liking.

    Please feel free to comment on any of the articles. Your opinion is always welcome here.


James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications


Get the latest workers' comp news FREE!

This field is for validation purposes and should be left unchanged.