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Body parts in MSA and settlement docs don't match
#1
I'm in California

My insurance company submitted an MSA proposal in 2017 listing 5 accepted body parts. CMS approved the proposal (with extra $ required).

Now the insurance company has given us draft settlement documents that only list one of those body parts (a very minor one) as accepted. They are stating in settlement docs that the other 4 body parts they had listed as accepted in the MSA are denied. There has been no medical-legal decision stating this denial and these 4 body parts are my biggest problems needing treatment.

I am very concerned this could be considered fraud against Medicare by shifting costs to Medicare. If it is fraud, I don't want to be a part of it.

Has anyone else had this happen? Or can anyone tell me if this is ok or not? I am very concerned.

Thank you.
 
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#2
(01-30-2018, 02:26 AM)Seeking Help Wrote: I'm in California

My insurance company submitted an MSA proposal in 2017 listing 5 accepted body parts. CMS approved the proposal (with extra $ required).  

Now the insurance company has given us draft settlement documents that only list one of those body parts (a very minor one) as accepted.   They are stating in settlement docs that the other 4 body parts they had listed as accepted in the MSA are denied.   There has been no medical-legal decision stating this denial and these 4 body parts are my biggest problems needing treatment.

I am very concerned this could be considered fraud against Medicare by shifting costs to Medicare.  If it is fraud, I don't want to be a part of it.

Has anyone else had this happen?     Or can anyone tell me if this is ok or not?  I am very concerned.

Thank you.
Generally the reason for a settlement buyout is a dispute between the parties.
if CMS is allowing the carrier to give you money to cover treatment to the disputed areas -- which you also believe is the carrier responsibility. -- how is that fraud?
Do you want the settlement $$$ reduced to only cover the area you both agree? Wouldn't that leave Medicare
With the entire coverage burden of the disputed parts?

A settlement is a compromise in return for not risking an all or nothing court decision.
Are you settling without an atty?
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
1171 I am curious, do you know if Medicare considers just the MSA proposal when determining what is considered an accepted WC injury or does it review the actual settlement documents signed by the IW? It makes me wonder why all body parts were listed in the MSA proposal even though they were not considered accepted? Maybe it is common to list all even those not accepted in the MSA?My concern would be how the injured worker moves forward with using Medicare after settlement, and can they use Medicare for the body parts not listed in the settlement agreement papers even though they are listed in the MSA proposal? Basically my question is does Medicare go by the body parts listed in the MSA or the body parts listed in the actual settlement agreement? In some ways this looks like it may help the injured worker.(not sure)
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
the settlement has to layout the nature and specifics of the dispute in order for the court to properly evaluate the proposal
yes the proposed settlement agreement is sent to CMS with a request for review.

"Always send medical records from all treating physicians for the last two years of treatment related to the work injury, even if the carrier has not paid for the treatment; even if future treatment is not allocated; and even if the treatment was long ago.....
If you believe the last two years of treatment are unrelated to the work injury, send those medical records in addition to those related to the work injury, along with any necessary explanation."

https://www.cms.gov/Medicare/Coordinatio...dHints.pdf
see also the downloads from the WCMSA site
https://www.cms.gov/Medicare/Coordinatio...rview.html

one of the weakness of the MSA process is the difficulty in arriving at an acceptable value when the parties are disputing the potential liability of a high cost medical condition as the range of possibilities/outcomes can be extreme and arriving at a similar future value by CMS can be almost impossible.
the whole process of negotiating a settlement amount between the opposing parties turns on how strongly each perceives their ability to prevail in an all or nothing trial. if CMS reviewers come to a significantly different valuation of that risk, and develop an alternative Set Aside amount then the settlement may not happen. it can be difficult enough to get 2 opposing comp attys to agree and then hopefully the comp court--- and now CMS as a fourth entity ---with unknown experience in the states comp laws and precedents.
MSAs seem to work best when there are fewer disputes or they are confined to disability or UR and not injury AOE/COE.
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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#5
[/quote]
Generally the reason for a settlement buyout is a dispute between the parties.
if CMS is allowing the carrier to give you money to cover treatment to the disputed areas -- which you also believe is the carrier responsibility. -- how is that fraud?
Do you want the settlement $$$ reduced to only cover the area you both agree? Wouldn't that leave Medicare
With the entire coverage burden of the disputed parts?

A settlement is a compromise in return for not risking an all or nothing court decision.
Are you settling without an atty?
[/quote]

I'm sorry if my original post wasn't clear. What concerns me is the C&R documents' reduction of accepted body parts from 5 to 1, which would mean those other 4 body parts (which were stated as accepted in the MSA proposal just 6 months ago) would now arbitrarily become Medicare's expense to cover. That seems like a clear shifting of responsibility to Medicare since there has not been any medical-legal report reversing the previous acceptance of those body parts.

It is my understanding that settlement docs go to Medicare after settlement so Medicare would obviously see these body parts being arbitrarily shifted onto them. That's not the deal CMS agreed to when they approved the MSA proposal.

Further, when defense attorney (DA) gave us draft settlement docs I was confused and said it didn't seem right to have the C&R docs disagree with body parts already accepted in the MSA docs. DA said to me something like, "If we do this, then you'll only have to use the MSA money on the 1 body part and not all 5, and you can use your Medicare insurance for the other 4." I told her I thought that was going to lead to problems and that I thought the body parts they stated as accepted in the MSA needed to also be stated as accepted in the C&R docs.

I would call the DA's suggestion which would shift those 4 body part to Medicare as being fraud.

I do have an attorney, but she has given me so much misinformation I can't rely on her statements without checking everything. My atty previously told me that she didn't know what a Medicare Conditional Payment is, so that gives an idea of her level of knowledge about this.

Hopefully I explained the situation better this time. Am I correct to refuse to agree to these C&R docs?
Thanks very much for your help!
 
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#6
(01-30-2018, 01:23 PM)1171 Wrote: You question is a bit confusing.
An MSA C&R doesn't confer Medicare eligibility on an otherwise ineligible worker.
It just reduces the ability of the worker to obtain a double recovery in cases where comp & Medicare are likely to overlap.
I believe this is the point of shadow's concern in an earlier post: MSA runs out and worker  is not yet eligible for Medicare.
http://www.workerscompensation.com/forum...?tid=17383
A Worker could have a gap in coverage.

Thank you ..that is exactly my concern . I am only 50 . The SSA could find that a person at this age can now transition in to some type of work . Of course there are hearings etc ... In this scenario they allow the claimant to keep Medicare for a short time but it will certainly end.

In my claim they ( The IC ) wanted to start the process .. I declined because of my age .When I turn 62 I would be interested in MSA....Maybe.

I think its risky ..just my humble opinion.

Back to the original poster : If you have settled your case or have clearly accepted body parts ... I would not settle with an MSA unless " all" body parts are listed . Just my humble opinion on this . It's complicated, probably need a good lawyer for this to protect you and all of your body parts. Then a second legal opinion if necessary. I have the same problem with an attorney. Except mine works for the other side on occasion.

Insurance Companies hate an open claim.

Be careful !
 
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#7
I'm sorry if my original post wasn't clear.   What concerns me is the C&R documents' reduction of accepted body parts from 5 to 1, which would mean those other 4 body parts (which were stated as accepted in the MSA proposal just 6 months ago) would now arbitrarily become Medicare's expense to cover.  That seems like a clear shifting of responsibility to Medicare since there has not been any medical-legal report reversing the previous acceptance of those body parts.  

It is my understanding that settlement docs go to Medicare after settlement so Medicare would obviously see these body parts being arbitrarily shifted onto them.  That's not the deal CMS agreed to when they approved the MSA proposal.

Further, when defense attorney (DA) gave us draft settlement docs I was confused and said it didn't seem right to have the C&R docs disagree with body parts already accepted in the MSA docs.  DA said to me something like, "If we do this, then you'll only have to use the MSA money on the 1 body part and not all 5, and you can use  your Medicare insurance for the other 4."    I told her I thought that was going to lead to problems and that I thought the body parts they stated as accepted in the MSA needed to also be stated as accepted in the C&R docs.  

I would call the DA's suggestion which would shift those 4 body part to Medicare as being fraud.

I do have an attorney, but she has given me so much misinformation I can't rely on her statements without checking everything.   My atty previously told me that she didn't know what a Medicare Conditional Payment is, so that gives an idea of her level of knowledge about this.

Hopefully I explained the situation better this time.  Am I correct to refuse to agree to these C&R docs?
Thanks very much for your help!




You can always refuse to settle especially when the conditions of a complex settlement are unclear.
---although you may have to switch attys if you go to trial.

is the comp carrier paying for treatment for the "disputed/denied" body parts now..?
is the comp carrier including some$$ for the permanent impairment of the "disputed/denied" body parts?

you have no guarentee that CMS will "buy" that argument when it comes time to pay and account for the MSA funds. you should ask for a written statement from CMS that they will in fact exclude treatment for those body parts in your MSA accounting. what happens to the value of your settlement if CMS does not exclude that treatment?
how do you appeal a possible adverse CMS decision on that issue?
will your atty or the Defense atty represent you?
can the terms of the C&R be changed to reflect an adverse CMS decision?
how can you be protected if the DAs understanding is wrong?

if there is no medical evidence to support a dispute in liability for those areas of the body, then it's not likely that CMS will pick up coverage outside the MSA amount just based on an unsubstantiated phrase in the C&R.
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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#8
Back to the original poster : If you have settled your case and have clearly accepted body parts ... I would not settle with an MSA unless " all" body parts are listed . Just my humble opinion on this . It's complicated, probably need a good lawyer for this to protect you and all of your body parts.
[/quote]

Thanks for your input, Shadow. My case has not settled yet. We are working to negotiate a C&R with the MSA. I do understand what you are saying about the "risk" of getting better and Medicare being taken away. I hadn't really thought of that, but my hope would be that if I improved enough that SSDI thought I was no longer disabled I could find work that would have insurance coverage. But I am glad you brought up your caution. I'm actually pretty close to 62.

The reality is that I'm getting so little care through work comp and the doctors are clearly lying now. The insurance company knife to their throat must be working. It's not in my best interest to go to any of them at this time and why I want out.
 
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#9
I don't seem to be getting emails notifying me of posts. I tried changing email addresses and wasn't able to get the email from the forum to verify the change.

There is no email in my spam folder.

Is there any way to find out if my ISP is bouncing back the emails from the forum and if so, what those bounce back messages say?

Thank you.
 
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#10
I reported your problem to the moderator.
I don!t use the email notification system so can't comment.
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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