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Workers Compensation Denied Claims

What is workers compensation: If you have a work-related injury or illness, your employer is required by law to pay for workers' compensation benefits. Workers' compensation provides medical care and financial assistance if you are injured or become ill as a result of your job. You could get hurt by: One event at work, such as hurting your back in a fall, getting burned by a chemical that splashes on your skin or getting hurt in a car accident while making deliveries. Repeated exposures at work, such as hurting your wrist from doing the same motion over and over or losing your hearing because of constant loud noise.

If you’ve been injured at work, you may be entitled to workers compensation. Worker's compensation is a state-mandated insurance program that benefits employees who are injured or become ill due to their job. However, not all worker's compensation claims are approved. In fact, many are denied. If your claim has been denied, you must be wondering what to do next. There are ways to fight back and get the benefits you deserve.

Benefits of Workers Compensation:

  • If you are injured or become ill as a result of your job, you may be entitled to certain benefits from your employer. These benefits include:
  • Medical care: Paid for by your employer to help you recover from an injury or illness caused by work
  • Temporary disability benefits: Payments if you lose wages because your injury prevents you from doing your usual job while recovering
  • Permanent disability benefits: Payments if you don't recover completely Supplemental job displacement benefits (if your date of injury is in 2004 or later):
  • Vouchers to help pay for retraining or skill enhancement if you don't recover completely and don't return to work for your employee.
  • Death benefits: Payments to your spouse, children or other dependents if you die as a result of the injuries or illness.

Denial or Acceptance of Work Injury:
Employees who are injured while working are required to fill out a work comp claim and provide that to their employer. Once the employer receives the completed claim form, they will submit it to their insurance company, who will then investigate the injury and determine if it is work related or not, Insurers or employers have to make a decision on work comp claim injury within 90 days of the receipt of the completed claim form.

Injured workers can seek treatment up to $10,000 in under medical treatment guidelines while the claims administrator considers your claim.

If the Claims Administrators decide that the work injury was not caused at work or is not related to work, that claim is known as a Denied Claim or Liability denial. In this article, we will explore what happens when a workers' compensation claim is denied and what your options are.

What to do when your claim for compensation is denied ?
When a claim is denied, it means the claims administrator believes your injury is not covered by workers’ compensation. If the claims administrator sends you a letter denying your claim, you have a right to challenge the decision. Don’t delay, because there are deadlines for filing the necessary papers. If you need help with your workers’ compensation claim, you can contact the Information and Assistance Unit. You may represent yourself or hire an attorney. If you contest the denial of your claim, your case will be heard by a workers’ compensation administrative law judge (WCJ).

When it comes to your workers' compensation claim, there might be some instances where you or the claims administrator doesn't agree with what your doctor has to say about your injury or treatment. If this happens, you might be evaluated by a qualified medical evaluator (QME). In order to qualify as a QME (Qualified Medical Evaluator), a physician must meet additional educational and licensing requirements. They must also pass a test and participate in ongoing education on the workers' compensation evaluation process. If you have an attorney, your attorney and the claims administrator might agree on a designated QME and those evaluators are known as AME (Agreed Medical Evaluator).

As a provider, if you are treating injured workers for denied claims on lien basis, we have a built-in mechanism to aid the collection process, which in turn allows you to recover your monies quickly and effectively. This will help you get paid for the work you're doing and help ensure that these workers receive the treatment they need.

Meraki RCM Solutions, LLC can help your practice turn Work Comp A/R into a continuous revenue stream. If you feel you need help in medical billing/collections or any part of the process that is overburdening your staff, we are here to lend our expert hand and provide the best services available.

Reach out to us at or call (562) 375-0472.

Tag: Medical Billing / workers compensation/ Denied Claims

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