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Calif UR doctors denying/Cashing out Medical. 1171
#1
Since the changes in California work comp laws of 2016, many of us have seen the increase in UR denials for treatment/medication.  For me, the denials started in September.  UR would send letters stating denial for medication that I had been taking for years or to be told "begin weaning process" all medications... medications will be denied after a certain date. Month after month, UR would request my doctor to call, he would call with me in front of him answer the question write letters to no avail. Only once did Ur overturn their decision. I've been paying for my medication out of pocket Two medications were $163. After talking to my adjuster the other day, she made me aware that UR will continue to deny payment for treatment and medication. The new laws are making Physician and Patients pulling out their hair out of frustration. Damned if you do and damned if you don't!  My adjuster suggested to contact my Attorney and begin the process of Cashing Out my Lifetime Medical I'm terrified at the thought of doing this especially since I'm on a fixed income with Social Security and my private insurance/Medicare.  My question to all of you... how is the Cashing out my lifetime medical Process. I read on here someone put the money in a trust for medical payment, but how/why does Medicare and my secondary insurance get notified... doctors have said I will have another cervical surgery above and below the current fusion C3-T1 I already had c4-c6 I'm so sorry I'm rambling but I'm completely lost on this subject. Any and all comments/suggestions/advice is greatly appreciated!
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
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#2
On large buyouts-$250k- Medicare pre-approves the treatment settlement amount.
If the carrier is still willing to settle then once the court approves the money goes to a third party administrator or to you to self -administer. I posted links to the CMS and set aside web sites in other recent posts. (Loki & bobcat)
All carriers are required to alert CMS of any comp claims to Medicare eligible workers.
This doesn,t apply to private insurers.
"Footer/signature" used in all my posts:
........Each state has their own comp system. We need to know your state to provide accurate information.........
 
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#3
If you are denied your medication by work comp, why are you not using Medicare? You can call Medicare and ask if they will cover denied WC medications. Many patients are using Medicare when WC denies treatment.

I wrote a detailed post on how to fight the UR denials. It is a very complicated system to appeal a UR denial.
http://www.workerscompensation.com/forum...?tid=17244
Addressing the reason for the denial is important as well as providing medical treatment guidelines.

UR will continue to deny these things until your doctor or you can effectively request and appeal them. IMR in my opinion is corrupt from my experience. Try to appeal the UR denials through the UR internal appeals process. These physicians have to provide their name unlike IMR and why I believe many IMR physicians are getting away with not reviewing or ignoring records sent in appeals that clearly address the UR denial.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#4
(08-04-2017, 11:34 AM)California_Help Wrote: If you are denied your medication by work comp, why are you not using Medicare? You can call Medicare and ask if they will cover denied WC medications. Many patients are using Medicare when WC denies treatment.

I wrote a detailed post on how to fight the UR denials. It is a very complicated system to appeal a UR denial.
http://www.workerscompensation.com/forum...?tid=17244
Addressing the reason for the denial is important as well as providing medical treatment guidelines.

UR will continue to deny these things until your doctor or you can effectively request and appeal them. IMR in my opinion is corrupt from my experience. Try to appeal the UR denials  through the UR internal appeals process. These physicians have to provide their name unlike IMR and why I believe many IMR physicians are getting away with not reviewing or ignoring records sent in appeals that clearly address the UR denial.
You have Medicare/Kaiser. They will not approve any medication per my PCP, my pain mt physician contacted Kaiser who also stated they will not authorize.  I've been paying out of packet since April and can't afford it... I've been only gettin medication when I can afford to as my rent and utilities and groceries are more important. This whole thing is scare for me. I just left my pain doctors office to discuss this only to be told "if you cash out it's on you we will not reduce our fees or provide a discount". It is what it is... my adjuster all of a sudden has told me to settle out which is weird    Just lost in California  bureaucracy
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
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#5
(08-04-2017, 11:12 AM)1171 Wrote: On large buyouts-$250k- Medicare pre-approves the treatment settlement amount.
If the carrier is still willing to settle then once the court approves the money goes to a third party administrator or to you to self -administer. I posted links to the CMS and set aside web sites in other recent posts. (Loki & bobcat)
All carriers are required to alert CMS of any comp claims to Medicare eligible workers.
This doesn,t apply to private insurers.
Thanks 1171,  I did find those posts on this Forum. Stayed up until 3:30 am researching. I'm just trying to figure out if this is the right thing to do!
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
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#6
there are many hoops to jump thru even if you decide to try. often the carrier won't accept the CMS evaluation of future medical and won't fund a set aside. then you're stuck where you are. since your adjuster is open to settlement it would be nice to know if they have a figure in mind. until there are specific amounts out in open its all speculation.
"Footer/signature" used in all my posts:
........Each state has their own comp system. We need to know your state to provide accurate information.........
 
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#7
(08-04-2017, 07:52 PM)1171 Wrote: there are many hoops to jump thru even if you decide to try. often the carrier won't accept the CMS evaluation of future medical and won't fund a set aside. then you're stuck where you are.  since your adjuster is open to settlement it would be nice to know if they have a figure in mind. until there are specific amounts out in open its all speculation.

You're probably right ??
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
Reply
#8
(08-04-2017, 05:30 PM)Babebahn Wrote:
(08-04-2017, 11:34 AM)California_Help Wrote: If you are denied your medication by work comp, why are you not using Medicare? You can call Medicare and ask if they will cover denied WC medications. Many patients are using Medicare when WC denies treatment.

I wrote a detailed post on how to fight the UR denials. It is a very complicated system to appeal a UR denial.
http://www.workerscompensation.com/forum...?tid=17244
Addressing the reason for the denial is important as well as providing medical treatment guidelines.

UR will continue to deny these things until your doctor or you can effectively request and appeal them. IMR in my opinion is corrupt from my experience. Try to appeal the UR denials  through the UR internal appeals process. These physicians have to provide their name unlike IMR and why I believe many IMR physicians are getting away with not reviewing or ignoring records sent in appeals that clearly address the UR denial.
You have Medicare/Kaiser. They will not approve any medication per my PCP, my pain mt physician contacted Kaiser who also stated they will not authorize.  I've been paying out of packet since April and can't afford it... I've been only gettin medication when I can afford to as my rent and utilities and groceries are more important. This whole thing is scare for me. I just left my pain doctors office to discuss this only to be told "if you cash out it's on you we will not reduce our fees or provide a discount". It is what it is... my adjuster all of a sudden has told me to settle out which is weird    Just lost in California  bureaucracy

Have you physically tried to take a prescription over to your pharmacy and ask them to run it under Medicare? Have you ever tried to call Medicare and explain your situation, you have medication denials from work comp and if they will pay for them? I do know many injured workers who have successfully been able to obtain medications and treatment by Medicare after work comp denied them. Medicare in turn placed a lien on the work comp carrier. Every situation is different, I understand.

Here is a link that states Medicare may pay for denied medications if you can show proof WC denied it. I would try submitting a UR denial or ask the pharmacy for a printout of the denial when they try to run the request through the WC carrier. Please try contacting Medicare about your issue.
https://www.medicare.gov/supplement-othe...ments.html
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#9
So I asked this question to several applicant attorneys, if you can use Medicare after UR has denied medications.

First attorney responded yes, but the Medicare lien would have to be dealt with at the time of settlement. Another attorney stated just yes, and the third attorney stated an injured worker can step outside of the CA WC system and use private insurance or Medicare any time you want, even without a claim denial or UR/IMR denial and Medicare will place a lien. Again, I recommend calling Medicare and see what they tell you and go by that.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
Reply
#10
(08-06-2017, 06:49 PM)California_Help Wrote: So I asked this question to several applicant attorneys, if you can use Medicare after UR has denied medications.

First attorney responded yes, but the Medicare lien would have to be dealt with at the time of settlement. Another attorney stated just yes, and the third attorney stated an injured worker can step outside of the CA WC system and use private insurance or Medicare any time you want, even without a claim denial or UR/IMR denial and Medicare will place a lien. Again, I recommend calling Medicare and see what they tell you and go by that.
 I did contact Kaiser and Medicare. I do not have part D I only have Part A & B (hospital/medical) I asked about sending or Even bringing in my letters of denial to Medicare to see what they could do only to be told "I'm sorry we will not cover your medication prescribed by your pain management physician who is not part of Kaiser
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
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