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Will WC carrier pay for out of state hotel (CA)
#11
(12-19-2017, 12:39 PM)California_Help Wrote:
(12-19-2017, 12:06 AM)kibby Wrote:
(12-17-2017, 12:38 PM)California_Help Wrote:
(12-16-2017, 01:25 AM)kibby Wrote:
(12-14-2017, 12:06 PM)1171 Wrote: Lke any expense request you nave to show necessity; it's not a blank Check for you to stay at the ritz
Come back if you need another copy or want it triple checked....Smile

Oh the Ritz would be excellent Tongue Yes, I know. I am just frustrated because my attorney refuses to go to court for my reimbursements. I  am owed a total of about 5k in reimbursements over the years and he sent me a nasty email today saying "how dare you demand I go to court" uh, I said go to court to get my money, yes. I can't keep waiting years for  a refund. 
Thanks again 1171!

I recommend calling your attorney to discuss. Just because you have out of pocket expenses does not mean the insurance carrier has to reimburse them. In 2013 the rules became stricter on for example treating with doctors outside of the MPN and also paying for treatment on your own without having a physician send with an RFA and get sent through UR and get approval first. I do not know your situation but recommend having a discussion with your attorney and ask him why he will not file for a hearing over this issue.
The aqua therapy I paid out of pocket for was one that a Workers Comp doctor referred me to. Unsure why he did that if he knew it would be denied. If that were the case, my attorney should go and ask the judge to pay it and the judge can tell him to fly a kite. It is really about my 4k in mileage that I would like back. He just refuses to go, that's the reason. I am trying to get another Attorney ASAP. 
The attorney has a new paralegal as of this summer, she is great. She got the IC to send a car for a three hour one way trip as well as a hotel. This paralegal could have helped me out in the beginning of the year to give me plane tickets for a trip back to my home state to pay the QME, unfortunately, that all came out of pocket. That is what I am trying to get reimbursed. A year later and no money has been reimbursed.

Your doctor had no idea if the insurance company was going to approve or deny the request. Many injured workers are getting denied everything under the sun. It is difficult for physicians to get certain things approved, aqua therapy included. Difficult but not impossible. I have overturned several aqua therapy denials. Aqua therapy is most commonly approved after surgery (not always) and/or when patient cannot tolerate land base therapy and has attempted home exercise without success. There is a 24 session limit.

Aquatic therapy is recommended as an optional form of exercise therapy, where available, as an alternative to land-based physical therapy. Aquatic therapy (including swimming) can minimize the effects of gravity, so it is specifically recommended where reduced weight bearing is desirable, for example extreme obesity (or for patients who cannot tolerate land base therapy due to their injury). For recommendations on the number of supervised visits, see Physical medicine. Water exercise improved some components of health-related quality of life, balance, and stair climbing in females with fibromyalgia, but regular exercise and higher intensities may be required to preserve most of these gains. (Tomas-Carus, 2007)

If your injury is for low back this is an example-
ODG-WC Low Back procedure Summary :The guidelines indicate that aqua therapy is recommended as an alternative to land therapy as it can reduce the effects of gravity, so it is specifically recommended were reduced weight bearing is desired.

Please note: I have seen reviewers incorrectly quote aqua therapy guideline to deny the request when the patient is not obese. This is incorrect as obesity was given as an example. If you cannot tolerate land base therapy due to pain, then you should qualify. Have you attempted land base therapy first and could not do it due to pain for example? Have you attempted home exercise without success? What body part is affected and why he is requesting the aqua therapy is important. I am writing this because it may (a big maybe) help you get reimbursed if you can incorporate a letter stating the denial was incorrect, based upon incorrect info( if that is the case). The days were applicant attorney's can take treatment denials to a judge to decide are over after 2013 (unless under a handful of circumstances).

With your mileage, unless your claim is denied or you were seeing a physician not within the insurance carriers MPN, or seeing a specialist not approved by UR I cannot see why they have not approved your mileage. It may be worth sending in your mileage again with a letter stating you want a 10% self imposed penalty. Just an idea, talk you your attorney or his paralegal over this.

Good luck.
Thanks for the info. I have talked with my attorney and he keeps saying he will have to go to court for the milege but doesn't want to. So, I am free to find another attorney(can't since they are already at a stipulated award stage) or wait a few years for him to finally go to court. It's alright. 
Take care
 
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#12
It cost them $350 dollars, one way to have them pick me up! Also, the doctor want's me to do Physical Therapy, two times a week. So, if that's the case, it'll be 1400 dollars a week just for a driver to come and get me. Wow, you would think they would find a closer doctor.
 
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#13
Is there anyway to force my attorney to go to workers comp court? I finally got a pharmacy card in the mail and they won't fill the script because when the pharmacist called to see why the card wouldn't work for this particular medicine the person told her "Claims adjuster does not feel this medication is deemed to be related to an occupational injury"

The next step to this would be obviously going in front of the WCAB? Correct? Going on two years and I am still without all my reimbursements and or voucher. Nobody will take this case over, I am stuck with him. Has anyone here had some specific wording I can give. He isn't afraid of getting reported to the bar.
I read that it goes to the UR(utilization review) Would my attorney need to send something in for this to happen? I can't afford paying out of pocket anymore.
 
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#14
yes, but they are illegal. forcing people to do what they voluntarily refuse to do mostly involves criminal coercion.
no.
california removed medical utilization review disputes from the comp court.
IMR info is here
http://www.dir.ca.gov/dwc/IMR.htm
as of 1/1 there is also a drug formulary in place
http://www.dir.ca.gov/dwc/MTUS/MTUS-Formulary.html
no. UR is not handled by your atty.
UR rules are here
http://www.dir.ca.gov/dwc/UR_Main.htm

try using your health insurance for services denied by workers comp.
settling your claim would also reduce your frustration with the system.
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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#15
(01-27-2018, 12:44 AM)1171 Wrote: yes, but they are  illegal. forcing people to do what they voluntarily refuse to do mostly involves criminal coercion.
no.
california removed medical utilization review disputes from the comp court.
IMR info is here
http://www.dir.ca.gov/dwc/IMR.htm
as of 1/1 there is also a drug formulary in place
http://www.dir.ca.gov/dwc/MTUS/MTUS-Formulary.html
no. UR is not handled by  your atty.
UR rules are here
http://www.dir.ca.gov/dwc/UR_Main.htm

try using your health insurance for services denied by workers comp.
settling your claim would also reduce your frustration with the system.
That drug list is interesting....
Yeah, I have used my own health insurance but I can't keep paying out of pocket and not getting reimbursed. Thanks for the info, this is probably the most helpful information I have yet.
 
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#16
(01-26-2018, 11:26 PM)kibby Wrote: Is there anyway to force my attorney to go to workers comp court? I finally got a pharmacy card in the mail and they won't fill the script because when the pharmacist called to see why the card wouldn't work for this particular medicine the person told her "Claims adjuster does not feel this medication is deemed to be related to an occupational injury"

The next step to this would be obviously going in front of the WCAB? Correct? Going on two years and I am still without all my reimbursements and or voucher. Nobody will take this case over, I am stuck with him. Has anyone here had some specific wording I can give. He isn't afraid of getting reported to the bar.
I read that it goes to the UR(utilization review) Would my attorney need to send something in for this to happen? I can't afford paying out of pocket anymore.

It is very difficult to respond on a message board. Claims adjusters can approve OR send the request through utilization review. Was it sent to UR or did your doctor do a request on a RFA form? There are several reasons why prescriptions get denied, both legally or illegally.  If this is for a denied body part they can refuse to send to UR.

I think it can be very difficult to receive treatment out of state for a CA work comp claim (IMO). The physician has to use a RFA form. There are treatment guidelines that should be used to get approval and California uses MTUS, Chronic pain, ODG and ACOEM 2nd edition guidelines, generally, however I have gone outside of these when condition is complex or does not fit these guidelines. Many CA physicians in the work comp system have difficulties with submitting what is needed to get authorization.
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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#17
(01-27-2018, 04:37 AM)kibby Wrote: That drug list is interesting....
Yeah, I have used my own health insurance but I can't keep paying out of pocket and not getting reimbursed. Thanks for the info, this is probably the most helpful information I have yet.

as med costs have spun out of control the last 15+ years most states have instituted heavy restrictions, limitations, and controls. the days of the blank check for the treating physician have all but been eliminated.
now there are lots of regulations and resulting high "friction" costs with work comp medical treatment.
california has no provision for atty fees for legal work on future medical awards.
these two factors make it difficult to use the lifetime treatment provisions of a comp award and have provided another incentive to buyout the balance of the benefits at MMI.

the guidebook link should have given you much of the same information on treatment disputes.
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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#18
It would be helpful if you provided the name of medication and condition it is being prescribed for. 

I still think your claims adjuster should have run it through utilization review, unless the request was not sent on and RFA form, is for an injury that is not accepted OR has been previously denied by UR within the last 12 months. (JMO)
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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#19
(01-28-2018, 01:57 PM)California_Help Wrote: It would be helpful if you provided the name of medication and condition it is being prescribed for. 

I still think your claims adjuster should have run it through utilization review, unless the request was not sent on and RFA form, is for an injury that is not accepted OR has been previously denied by UR within the last 12 months. (JMO)

Well, now they just denied my Injections I was supposed to go but I had the appointment rescheduled due to another dr appointment. Good thing or else they would have been on the hook. They sent out the denial on the day I was supposed to have them. Thoracic, neck and lumbar injury is worthless with CIGA
 
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#20
(02-02-2018, 08:46 PM)kibby Wrote:
(01-28-2018, 01:57 PM)California_Help Wrote: It would be helpful if you provided the name of medication and condition it is being prescribed for. 

I still think your claims adjuster should have run it through utilization review, unless the request was not sent on and RFA form, is for an injury that is not accepted OR has been previously denied by UR within the last 12 months. (JMO)

Well, now they just denied my Injections I was supposed to go but I had the appointment rescheduled due to another dr appointment. Good thing or else they would have been on the hook. They sent out the denial on the day I was supposed to have them. Thoracic, neck and lumbar injury is worthless with CIGA

I am surprised your doctor was going to do it without receiving an approval first. They may not have been on the hook if the denial was timely.

If you read your denial there should be two ways you or your doctor can appeal it. First through the internal UR appeal process and then through IMR. There are time limits with both. They should have stated why it was denied and the rational they used to deny it. Just FYI these are not always accurate and many times requests are denied due to lack of information. There are ways to appeal some of these denials (not always). If your doctor is well versed in WC he may know how to appeal this, but there are strict time limits.
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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