Have you experienced the frustration of having an insurance adjuster reject your Treatment Plan for reasons you don’t understand?

Here are 10 tips that can lead to more approved Treatment Plans:

1.  Submit Treatment Plans only after Application for Accident Benefits (OCF 1) and Disability Certificate (OCF 3) are complete and submitted to the insurer. The insurer has no obligation to respond to a Treatment Plan until the Application is received. Call the client or the law firm to find out.

2.  Find out if your client has any collateral benefits. AB insurers are second payors after any collateral benefits insurers. Ask the client, insurer or law firm if there are any collateral benefits before the Treatment Plan to save you time and unnecessary expense.

3.  Fully complete the Treatment Plan – Adjusters are trained to check for completeness and will reject Treatment Plans simply because there is missing or incomplete information. Each of the following sections should be completed:

  • Injury and Sequelae Information – Insert appropriate codes with as much detail as possible;
  • Prior or concurrent conditions – Complete to the extent of your knowledge, information and belief. If “unknown” it’s okay to indicate this;
  • Activity Limitations;
  • Plan Goals, Outcome Evaluation Methods and Barriers to Recovery – This is the key to the Treatment Plan and should fully explain the proposed treatment, why it is required and how the results will be measured. Include as much detail as possible; and
  • Policy/Claim number, Adjuster’s Name, Insurer Information and correct date of loss. Adjusters can carry hundreds of claims files and will not necessarily know your client’s name and may sit on a Treatment Plan designating it as “un-matched” if this information is not inserted.

4.  Explain the Treatment Plan to the client. Your client’s minimal medical rehabilitation dollars will be spent on your treatment. Explain your proposed treatment so that they can make an informed decision.

5.  Ask your client to sign the Treatment Plan. As a rule, your client should sign the Treatment Plan before it is submitted. If your client lives a distance away, then contact the insurer to obtain their consent to accept the treatment plan un-signed until you meet with the client.

6. Explain the Treatment Plan to a Regulated Health Care provider on the Team if requesting their signature on the Treatment Plan.

7. Submit Treatment Plans for reasonable and necessary items and services. Some health care providers are dissuaded by the prospect of a refusal. If you don’t ask you will never know and your client will not receive the services.

8. Communicate. Timely phone calls to insurance adjusters or legal teams can save time and money. You can explain your rationale and sometimes even obtain verbal approval. Even if there is a denial a simple phone call can sometimes change the adjuster’s mind. Pick up the phone – don’t e-mail.

9. Only submit Treatment Plans in excess of $250 or for items/services required more than five days after the accident. Treatment Plans are not required for items/services less than $250 or for emergency items incurred up to five days after an accident.

10. Only submit Treatment Plans for items or services, not medication. Treatment Plans are not required for medication prescribed by a physician.

Author: Team Teggart