Understanding Prescriptions in the Workers' Compensation System
Updated: September 10, 2020
ArticleUnderstanding the doctor’s role, your pharmacies’ role, your attorney’s role, and the workers’ compensation insurance company’s obligation is critical in the prescription process.
Understanding who is involved is important in understanding the process.
The injured workers which is you.
The doctors; that can be your primary workers’ compensation doctor, a surgeon, a pain management doctor, etc.
The pharmacies are involved and must be active in the authorization process; often they are not and cause most of the friction in the system.
For my Safety personnel and other state workers such as my correctional officers and parol officers with CDCR, my firefighters with CAL Fire, my California Highway Patrol, you’re dealing with a legally uninsured state agency administrated by State Compensation Insurance Fund.
My city and county firefighters, county sheriff, and city police officers are dealing with a self-insured pool administered by a private claims administrative company like Corvel, York, Keenan & Associates, Sedgwick, etc.
All non-safety cases are generally insured by private insurance companies.
All of these are different in who handles authorizations for prescriptions, but they all follow the same process dictated by the law specifically Labor Code Section 4610.
After you see your doctor, they will recommend prescriptions. As with your private doctors, the doctor will hand you a prescription note before you leave the appointment.
Many of our clients will then go to the pharmacy and try to fill the prescription; however, workers’ compensation is not like normal insurance. The doctor’s note allows the pharmacist to release the prescription to you, but does not authorize payment by the insurance company.
A Request for Authorization (RFA) process must be done, so the insurance company can authorize payment to the pharmacy. So, you can’t pick up the prescription until the insurance company authorizes it.
When you leave your doctor’s appointment, ask the staff how you should expect to wait for the authorization to be requested, so you understand the realistic time lines. Explain to them that you are not intending on rushing them, because you know they’re busy, but you want realistic expectations on how the process works.
Once the doctor requests the authorization [Request for Authorization Form (RFA)], the insurance company has five business days counted from the next business day after they receive the RFA. Most doctors fax it.
As you can see, it’s important to know WHEN the doctor actually fills out the RFA, because the insurance company is under no obligation to do anything (and the five day clock does not start running) until they receive that form.
Once the insurance company has received the form, they have five business days to respond. That response must be an approval, a denial, or an authorization with changes in what what was requested (called a Modification).
No Response from the Insurance Company
If the doctor faxed the RFA, five business days has passed, then the doctor’s office should do the following:
- Print the RFA
- Print proof that they faxed the RFA (this a fax confirmation from their fax system)
- Fax the RFA, the fax confirmation sheet, and a fax cover sheet to your attorney indicating the RFA has not been responded to in five days.
When they don’t, your attorney is stuck in a situation where they are not aware that the RFA has not been responded to and can’t do anything even if they aware, because they don’t have the evidence needed to prove the problem to a Judge.
You should encourage your doctors’ offices to fax all medical reports as they are generated to your attorney and use the process described above when the request for authorization isn’t responded to by the insurance company.
Prescription Authorized; No Authorization to Pharmacy
A common problem is that the medications are authorized; in a lot of cases, my clients have the authorization, we have the authorization, but the pharmacy is told by the insurance company that it hasn’t been authorized.
This situation occurs when the insurance company’s third-party service does not know that the insurance company authorized the medication. This is a classic “left hand does not know what the right hand is doing” situation.
The pharmacies often frustrate the process by not using common sense. The pharmacy should take a copy of the authorization letter you have, fax it to the third-party company and ask them to authorize it.
The fastest way to getting your medications is for your pharmacy to contact the third-party service and your adjuster directly. Many will say “it’s not their job,” and that can be frustrating for our clients.
Otherwise, your attorney will have to request the insurance company contact the third-party service and clarify the mistake.
Your attorney will then need to follow-up with the insurance company. Your attorney can request a hearing with a Judge on that treatment / prescription if the insurance company violated the time lines and procedures required for the RFA process.
By understanding who the parties are and their role in the medical treatment process, you reduce frustration with a system filled with red tape.