Oregon Workers' Compensation and Medical Benefits: Common Issues

Every Oregon Workers' Compensation claim involves medical treatment of some kind, regardless of the injury.  However, getting the medical care you deserve can be complicated.  Here is a checklist of some of the issues that can affect your access to medical care.

1.  Your Accepted Condition

When your claim is accepted, the insurance company has to issue a notice of acceptance, which notifies you what medical condition the insurance company is taking responsibility for.  This is important, because the insurance company is limited to providing medical service for the accepted condition.  For example, if the accepted condition is a lumbar strain, you are entitled to the medical care needed to treat a strain.  But, if in reality, you suffered a herniated disc, you may not get the required medical care because the disc injury is not the accepted condition.  So, it is important to know what condition is accepted.  If other conditions need to be included in your claim, you can make that request.

2.  Medical Necessity Denials

Sometimes, the insurance company will accept all of the medical conditions caused by your on the job injury, but you still may be denied treatment.  This is because the insurance company has decided that the proposed treatment is not "medically necessary."  You can appeal this denial to the Oregon Workers' Compensation Division.

3.  Compensability Denials

Sometimes, the insurance company will deny the proposed treatment, not because it is not necessary, but it is really aimed at treating a condition that is not part of the accepted condition.  This is true even if the insurance company has accepted all of the medical problems that resulted from the on the job injury.  You can appeal these denials as well, and if the Workers' Compensation Division finds that this is the reason for the denial of medical care, it will send your case to the Workers' Compensation Board to be assigned to a Judge for a hearing.

4.  The Attending Physician

The "attending physician" is the doctor that directs the care of your accepted worker's compensation claim.  There are special rules that dictate who can, and who cannot be the attending physician on your claim.  If you are not treating with the attending physician, you may be denied care and medical benefits.

5.  Managed Care Organizations

Managed Care Organizations, or "MCOs" are managed care groups that insurance companies contract with to manage or oversee the medical benefit portion of a claim.  If your insurance company contracts with an MCO, you can only treat with a doctor enrolled in the MCO, or a doctor that agrees to follow MCO rules.  If proposed medical care is denied, you can appeal the denial, but you must appeal first with the MCO.

6.  Open Claim/Closed Claim

When your claim is open, you are entitled to care that is aimed at restoring function, also called "curative" care.  But, once your claim is closed, medical benefits are limited.  There are many rules, but essentially, the care that you are entitled to is care to maintain your function, not to cure it. 

So, if you are having trouble getting medical benefits, there could be many issues between you and your medical care.  We can look at your claims file, and help you know where you stand with the claim, and whether you have options.  If we go to bat for you, we are only paid if we are successful, and in many medical disputes, the insurance company pays our fee.

Call us at 503-325-8600 to find out your options.