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Medicare Set-aside
#1
Hi,

I'm in California and recently settled part of my worker's comp case. The worker's comp part was settled by Compromise and Release, leaving the Medicare set-aside part of the case open for future settlement. CMS have recently decided the set-aside amount, with me as the account administrator. Attorneys for the defendant are aware of the CMS set-aside amount and yet they, or the insurance company they represent, or both, are ignoring the payment. 

I feel like the set-aside has fallen into a black hole. My attorney seems to be as stumped as I am, offering no help except to say that I need to paper them with RFA's for the meds and treatment I need. I wouldn't even know where to send the RFAs. Medicare won't cover the meds since it's a worker's comp situation, so it will have to come out of my own pocket. (I am of Medicare age.)

Any help would be appreciated.
 
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#2
Your atty is incorrect.
A Request For Authorization is to be completed and signed by the treating physician; its not the injured worker's responsibility.

An RFA is a form that the doctor is required to use to request treatment, diagnostic tests or other medical services for an injured worker. If the treatment request was first made verbally, it must be confirmed in writing. The treating physician must fill out the form and attach the doctor's first report of occupational injury or illness (form DLSR 5021), the primary treating physician progress report (DWC form PR-2), or a narrative report that contains the same information required in the primary treating physician progress report form.

http://www.dir.ca.gov/dwc/utilizationreview/ur_faq.htm

often times your health insurer will cover treatment denied by the comp carrier.

medical can be settled without a set aside but there is a risk that medicare will not pick up coverage when the treatment dollars run out if they believe the settlement amount for medical was inadequate.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#3
Many thanks for the info.
 
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#4
you're welcome; glad it helped.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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