If the insurance company is delaying or denying your workers’ compensation medical benefits, call Graves Law at (407) 308-0327 for a free consultation. We represent injured workers throughout Florida on a contingency fee basis. You pay nothing unless we recover benefits for you.
Florida Workers' Compensation Medical Treatment
INJURED AT WORK? YOU MAY BE ENTITLED TO WORKERS' COMP MEDICAL BENEFITS
When you are injured on the job in Florida, your employer’s workers’ compensation insurance carrier is required by law to pay for all medically necessary treatment related to your workplace injury. That obligation begins the moment you are hurt and continues through your recovery. In practice, however, insurance carriers routinely delay authorizations, question medical necessity, deny recommended procedures, and pressure injured workers to accept less care than they need. A workers’ compensation lawyer can help navigate this complex system.
This page explains exactly what medical benefits Florida law requires, how the system works from the first emergency room visit through Maximum Medical Improvement, and what to do when the insurance company refuses to provide the care your doctor has recommended. Call Graves Law at (407) 308-0327 for a free consultation if you are having trouble getting authorized medical care after a workplace injury.
“Under Florida law, your employer and their insurance company are supposed to provide and pay for all medically necessary treatment related to your work injury. But in reality, insurers often push back on care, question doctor recommendations, or delay authorizations. At Graves Law, we help injured workers get the care they need and hold insurance carriers accountable.”
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The Legal Foundation: Florida Statute § 440.13
Florida’s workers’ compensation medical benefits are governed by Florida Statute § 440.13. The core obligation is stated in § 440.13(2)(a): the employer shall furnish to the employee such medically necessary remedial treatment, care, and attendance for such period as the nature of the injury or the process of recovery may require.
Three phrases in that statute are critical to understanding your rights:
- Medically necessary means treatment that is reasonably required by the nature of your injury. The insurer cannot simply refuse care because it is expensive or inconvenient. The standard is whether the treatment is appropriate for the medical condition.
- For such period as the nature of the injury requires means the obligation does not have a fixed time limit. Coverage continues as long as your condition requires treatment, not just until a set number of weeks have passed.
- The employer shall furnish is a mandatory obligation, not a discretionary one. The carrier does not have the option to decline treatment it determines is medically necessary.
When a carrier denies or delays treatment it has an obligation to provide, an injured worker can file a Petition for Benefits with the Office of Judges of Compensation Claims to enforce the right to medical care.
Emergency Medical Care
Florida Statute § 440.13(3)(a) explicitly provides that emergency care may be rendered without the carrier’s prior authorization. You do not need to wait for the insurance company to approve treatment in a genuine medical emergency.
Emergency care coverage applies in two situations. First, immediately after a workplace accident when you require emergency treatment before a workers’ compensation claim has even been opened. An ambulance transport to the hospital after a construction fall, for example, is covered. Second, during an ongoing claim when a new emergency arises and your authorized treating physician is unavailable.
For emergency treatment during an ongoing claim to be covered without prior authorization, two conditions must be present: the situation must constitute an actual medical emergency, meaning your health or a bodily organ or function would be placed in serious jeopardy without immediate care, and you must attempt to contact your authorized treating physician before seeking emergency treatment if they are reasonably available.
Emergency Treatment: Three Illustrative Scenarios
Covered: After spine surgery, you lose feeling in your legs overnight. You call your surgeon’s office but it is closed at midnight. You go to the emergency room for emergency evaluation. This is covered because it was a genuine emergency and your physician was unavailable.
Covered: You are injured on a construction site, an ambulance is called, and you are transported to the ER before any claim is filed. The carrier pays for the emergency transport and initial treatment.
Not Covered: After spine surgery, you believe your pain medication is insufficient. You go to the ER instead of calling your physician’s office during business hours. This is likely not covered because it was not a genuine emergency and you did not attempt to contact your authorized provider.
The Authorized Treating Physician
Once your condition is stabilized after a workplace injury, the workers’ compensation carrier selects an authorized treating physician to manage your ongoing care. This is one of the most important and often misunderstood aspects of Florida workers’ compensation.
Surgeries and Specialist Referrals
Once your condition is stabilized after a workplace injury, the workers’ compensation carrier selects an authorized treating physician to manage your ongoing care. This is one of the most important and often misunderstood aspects of Florida workers’ compensation.
The Carrier Controls the Choice of Doctor
Under Florida workers’ compensation law, the employer or its insurance carrier generally has the right to select your authorized treating physician. You do not choose your own doctor. Seeking treatment from a physician the carrier has not authorized is typically done at your own expense and will not be reimbursed under the workers’ compensation claim.
This is a significant difference from health insurance or personal injury claims where you choose your own provider. The carrier’s control over physician selection is one of the reasons injured workers often receive less aggressive treatment recommendations than they would from a doctor of their own choosing.
One-Time Change of Physician
Florida Statute § 440.13(2)(f) gives injured workers the right to request a one-time change of authorized treating physician. To exercise this right, you must request the change in writing to the carrier. Once you make this request, the carrier has five days to provide you with a new authorized physician. If the carrier does not respond within five days, you may select your own physician from within the workers’ compensation network, and that physician becomes your authorized treating physician.
The one-time change is a significant right that many injured workers do not know they have. If you are receiving care from an authorized physician whose recommendations you believe are inadequate or who is not taking your injuries seriously, contact Graves Law before exercising this right to make sure it is used strategically.
Independent Medical Examinations
The carrier may request that you submit to an Independent Medical Examination (IME) by a physician of the carrier’s choosing. Despite the name, IME physicians are retained by and paid by the insurance carrier. IME physicians frequently produce reports that dispute the severity of injuries, challenge the medical necessity of recommended treatment, or suggest earlier Maximum Medical Improvement than your treating physician recommends.
You are generally required to attend a carrier-requested IME. However, you have the right to have your own physician present during the examination, and you should carefully review the IME report with your attorney before it is used to deny or reduce your benefits.
If the carrier uses an IME report to deny recommended treatment, your attorney can challenge the IME findings through the Petition for Benefits process and by obtaining competing medical opinions.
INJURED AT WORK?
If you were hurt at work don’t suffer longer, let an experienced work injury lawyer secure your benefits now. Get a free, no-obligation consultation with a trusted Florida workers’ comp lawyer. Call (407) 308-0327 today.
What Medical Treatment Is Covered
Subject to the authorized treating physician requirement and medical necessity, Florida workers’ compensation covers a comprehensive range of medical services under § 440.13:
Primary Care and Specialist Visits
All visits to your authorized treating physician are covered. If your authorized physician refers you to a specialist, that specialist referral must also be authorized by the carrier. Specialist services that are medically necessary and properly referred are covered. If the carrier denies a specialist referral your treating physician has requested, you can challenge that denial through a Petition for Benefits.
Diagnostic Imaging
X-rays, MRIs, CT scans, nerve conduction studies, and other diagnostic imaging ordered by your authorized treating physician are covered when medically necessary. Carriers frequently dispute the need for advanced imaging, particularly MRIs. If your physician orders imaging and the carrier denies it, that denial is directly challengeable.
Surgery
Surgery recommended by your authorized treating physician is covered when it is medically necessary. Common covered surgeries include spinal procedures including discectomy, laminectomy, and spinal fusion, shoulder surgeries including rotator cuff repair and labrum repair, knee procedures including meniscus repair and ACL reconstruction, carpal tunnel release, and hernia repairs related to workplace injury.
The carrier must authorize surgery before it is performed except in genuine emergencies. Advance authorization is critical. Do not schedule surgery without first confirming the carrier has issued written authorization. If the carrier denies authorization for recommended surgery, contact Graves Law immediately to challenge the denial through a Petition for Benefits.
Physical Therapy and Rehabilitation
Physical therapy, occupational therapy, and other rehabilitation services ordered by your authorized treating physician are covered. The carrier may limit the number of therapy sessions initially authorized and require re-authorization for continued treatment. If therapy is medically necessary and the carrier stops authorizing sessions before your treating physician recommends discontinuing them, that denial can be challenged.
Prescription Medications
All medically necessary prescription medications written by your authorized workers’ compensation physician are covered under Florida Statute § 440.13(12). Carriers use pharmacy benefit managers (PBMs) and generally require prescriptions to be filled at approved pharmacies. You should not be paying out of pocket for medications your authorized physician has prescribed for your work injury. If you are being asked to pay for covered medications, contact Graves Law.
Pain Management
Pain management services, including injections and pain management specialist visits, are covered when authorized by the carrier as medically necessary. Carriers frequently resist pain management referrals in an effort to move injured workers toward Maximum Medical Improvement sooner. If your authorized treating physician has referred you for pain management and the carrier is refusing to authorize it, that refusal is challengeable.
Durable Medical Equipment
Medical equipment prescribed by your authorized treating physician is covered under Florida Statute § 440.13(2)(a). This includes crutches, walkers, wheelchairs, orthopedic braces and supports, TENS units, CPAP machines, hospital beds, and wound care supplies. The equipment must be prescribed by your authorized physician, not merely recommended or suggested.
Transportation to Medical Appointments
Florida Statute § 440.13(13) entitles injured workers to reimbursement for transportation to and from authorized medical appointments. You may be reimbursed for mileage at the state-approved rate, parking fees, and tolls. If you are unable to drive due to your injuries, transportation services may also be covered. Keep a mileage log and receipts for every medical appointment and submit reimbursement requests promptly to the carrier.
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Treatment the Carrier Can Dispute or Deny
Not every treatment your physician recommends will be automatically approved. Understanding the common grounds for carrier disputes helps you anticipate problems and protect your right to care:
- Medical necessity disputes. The carrier may argue that a recommended treatment is not medically necessary even when your physician has ordered it. The carrier uses its own medical reviewers and IME physicians to generate opinions supporting denial. These decisions can be challenged.
- Authorization delays. Carriers sometimes delay authorizing treatment without formally denying it. Extended delays in authorization can constitute a constructive denial that is subject to a Petition for Benefits. Florida law requires timely responses to authorization requests.
- Causation disputes. The carrier may argue that a particular condition was pre-existing and not caused or aggravated by the workplace injury. Pre-existing condition arguments are among the most common grounds for treatment denial. An attorney can help document the connection between the injury and the treatment being sought.
- Preferred provider restrictions. Carriers may attempt to limit treatment to providers within their network when the appropriate specialist or facility is outside that network. If medically appropriate care is not available within the carrier’s network, the carrier must provide access to appropriate care outside the network.
Maximum Medical Improvement
Maximum Medical Improvement (MMI) is the point at which your authorized treating physician determines that your condition has stabilized and is not expected to improve further with additional medical treatment. MMI does not mean you are fully recovered or pain-free. It means your condition has reached a plateau.
MMI is a critical transition point in your workers’ compensation claim for several reasons:
- Your temporary wage replacement benefits (Temporary Total Disability or Temporary Partial Disability) end when you reach MMI.
- Your authorized physician assigns a Permanent Impairment Rating (PIR) based on the Florida Uniform Permanent Impairment Rating Schedule, which determines your eligibility for Impairment Income Benefits.
- After MMI, you can continue to see your authorized treating physician for palliative care, but you are required to pay a $10.00 copay per visit, and the nature of treatment shifts from curative to maintenance.
- If you believe your physician has placed you at MMI prematurely, your attorney can challenge the MMI determination through the Petition for Benefits process and by obtaining an Independent Medical Examination from a physician of your own choosing under certain circumstances.
What to Do When the Carrier Denies or Delays Your Medical Care
If the insurance carrier is refusing to authorize treatment your authorized treating physician has recommended, or is delaying authorization without a clear reason, you have legal remedies:
- File a Petition for Benefits with the Office of Judges of Compensation Claims. This is the primary enforcement mechanism for workers’ compensation rights in Florida. It initiates a formal proceeding before a Judge of Compensation Claims who has authority to order the carrier to provide the disputed treatment.
- Request a utilization review of any denied treatment under Florida Statute § 440.13(6). The carrier must conduct a utilization review before denying treatment based on medical necessity, and that review process creates a record you can challenge.
- Obtain medical opinions from your own physicians. While you generally must treat with the authorized physician during the claim, you can consult with your own doctors to obtain opinions that challenge IME findings or support the medical necessity of denied treatment.
- Contact Graves Law at (407) 308-0327. We handle medical benefit disputes for injured workers throughout Florida and can often resolve authorization disputes without litigation by making clear to the carrier that we are prepared to file a Petition for Benefits.
Frequently Asked Questions
Does workers comp in Florida cover emergency room visits?
Yes. Emergency treatment does not require prior authorization under Florida Statute § 440.13(3)(a). If the situation is a genuine medical emergency and your authorized physician is unavailable, go to the nearest emergency room. Keep documentation of your attempts to contact your authorized physician before seeking emergency care.
Can I choose my own doctor for a Florida workers’ compensation injury?
Generally no. The employer or insurance carrier selects your authorized treating physician. You have a one-time right to request a change of physician under § 440.13(2)(f). If the carrier does not respond to your written request within five days, you may select a physician from within the workers’ compensation network.
What if the carrier denies surgery my doctor recommended?
You can challenge the denial by filing a Petition for Benefits with the Office of Judges of Compensation Claims. Do not have surgery without authorization unless it is a genuine emergency, as unauthorized treatment is typically not covered. Contact Graves Law to discuss your options before the surgery is scheduled.
Are prescription medications covered?
Yes. All medically necessary medications prescribed by your authorized workers’ compensation physician are covered under § 440.13(12). Most carriers require prescriptions to be filled at approved pharmacies through their pharmacy benefit manager.
What is an IME and do I have to attend?
An Independent Medical Examination is an examination by a physician retained by the insurance carrier to evaluate your condition. Despite the name, IME physicians are paid by the carrier. You are generally required to attend a carrier-requested IME. You have the right to have your own physician present during the examination. IME reports frequently dispute injury severity or recommend earlier MMI. Contact Graves Law before your IME so we can prepare you for what to expect.
What happens to my medical care after MMI?
After Maximum Medical Improvement, you can continue to see your authorized treating physician for palliative care to manage ongoing symptoms. You will be required to pay a $10.00 copay per visit after MMI. Curative treatment generally ends at MMI, though you may still be entitled to Impairment Income Benefits based on your permanent impairment rating.