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Body parts in MSA and settlement docs don't match
#11
(01-30-2018, 04:46 PM)Shadow Wrote:
(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 !

I edited out my original response to cal help as I didn't think it answered the concerns that they posted.
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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#12
(01-30-2018, 10:07 PM)1171 Wrote:
(01-30-2018, 04:46 PM)Shadow Wrote:
(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.

Be careful in your decision .

I edited out my original response to cal help as I didn't think it answered the concerns that they posted.
 
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#13
(01-30-2018, 05:38 PM)Seeking Help Wrote: 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.

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.
[/quote]

I hear of people saying they can get coverage for a comp injury on a private policy ..I find it interesting people say that. When I look at the Evidences of Coverage for say a Blue Cross policy it contains a subrogation clause that precludes third party claims and the insured must notify the carrier that some one else holds iability for the medical bills within 60 days so the carrier can lien other claims. Such as a comp carrier. I suspect ( but i dont know for a fact ) that people are not being honest when having another insurance company pay medical bill that arose from a work injury. I was taught that no private insurance company is going to accepts liability for medicals that another hold liability for. I have just never seen it ..maybe I'm wrong. Typing is hard for me due to disability. I feel your frustration. Call a private medical insurer and ask .. I think the answer is going to be No ! or they will and maintain subrogation rights.
 
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#14
(01-31-2018, 02:33 AM)Shadow Wrote: I hear of people saying they can get coverage for a comp injury on a private policy ..I find it interesting people say that. When I look at the Evidences of Coverage for say a Blue Cross policy it contains a subrogation clause that precludes third party claims and the insured must notify the carrier that some one else holds iability for the medical bills within 60 days so the carrier can lien other claims. Such as a comp carrier. I suspect ( but i dont know for a fact ) that people are not being honest when having another insurance company pay medical bill that arose from a work injury. I was taught that no private insurance company is going to accepts liability for medicals that another hold liability for. I have just never seen it ..maybe I'm wrong. Typing is hard for me due to disability. I feel your frustration. Call a private medical insurer and ask .. I think the answer is going to be No ! or they will and maintain subrogation rights.

You make good points. Thank you, Shadow. I was thinking that group insurance from an employer would not exclude pre-existing conditions. But the work injury would not just be pre-existing, it would also be a different insurer's liability, unless those body parts were truly and legitimately denied to be part of the work injury.

I'm pretty sure I have read in CMS documents that if a person with an MSA loses Medicare coverage they are still allowed/required to pay for the specific body parts out of the MSA. That is, the MSA money is not frozen if a person loses Medicare coverage. But as you've mentioned, if the MSA amount is inadequate it could run out before the person reaches retirement age when they're automatically eligible for Medicare.

I feel quite confident my MSA amount will get me through until my full retirement age, or age 62 at least, but your cautions are very important, particularly for a younger worker to consider.
 
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#15
(01-31-2018, 07:29 PM)Seeking Help Wrote:
(01-31-2018, 02:33 AM)Shadow Wrote: I hear of people saying they can get coverage for a comp injury on a private policy ..I find it interesting people say that. When I look at the Evidences of Coverage for say a Blue Cross policy it contains a subrogation clause that precludes third party claims and the insured must notify the carrier that some one else holds iability for the medical bills within 60 days so the carrier can lien other claims. Such as a comp carrier. I suspect ( but i dont know for a fact ) that people are not being honest when having another insurance company pay medical bill that arose from a work injury. I was taught that no private insurance company is going to accepts liability for medicals that another hold liability for. I have just never seen it ..maybe I'm wrong. Typing is hard for me due to disability. I feel your frustration. Call a private medical insurer and ask .. I think the answer is going to be No ! or they will and maintain subrogation rights.

You make good points.  Thank you, Shadow.  I was thinking that group insurance from an employer would not exclude pre-existing conditions.  But the work injury would not just be pre-existing, it would also be a different insurer's liability, unless those body parts were truly and legitimately denied to be part of the work injury.

I'm pretty sure I have read in CMS documents that if a person with an MSA loses Medicare coverage they are still allowed/required to pay for the specific body parts out of the MSA.  That is, the MSA money is not frozen if a person loses Medicare coverage.  But as you've mentioned, if the MSA amount is inadequate it could run out before the person reaches retirement age when they're automatically eligible for Medicare.  

I feel quite confident my MSA amount will get me through until my full retirement age, or age 62 at least, but your cautions are very important, particularly for a younger worker to consider.
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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#16
It is not required that you have an MSA.
The set aside amount is the workers to with as they will but.....
Medicare will withhold coverage until the approved amount has been accounted for by the worker.
Again preventing as much double recovery/cost shifting as practical.
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.
 
Reply
#17
(01-30-2018, 05:34 PM)1171 Wrote: 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.
Hopefully we can modify the C&R documents so that all parties are satisfied.

May I ask for clarification as to why you say I may need to switch attys if I go to trial?

(01-30-2018, 05:34 PM)1171 Wrote: is the comp carrier paying for treatment for the "disputed/denied" body parts now..?

Yes, the w.c. carrier has been paying for treatment for those body parts now claimed in draft C&R documents to be denied. The treatment itself has been mediocre, but yes the IC has been paying for those "disputed/denied" body parts. I have copies of the Explanation of Benefits with those exact diagnosis codes (and no other dx codes) listed.

(01-30-2018, 05:34 PM)1171 Wrote: is the comp carrier including some$$ for the permanent impairment of the "disputed/denied" body parts?
Yes, they have said in one place in C&R documents that PD amount is based on a specific med/legal doctor's opinion. That doctor clearly opined that the (now supposedly denied) body parts are accepted. However in a different place in C&R documents the IC has blatantly misquoted that same med/legal doctor as to which body parts he stated were accepted. Clearly the blatant misquote is an attempt to substantiate their baloney that the accepted body parts are denied.
(01-30-2018, 05:34 PM)1171 Wrote: 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

Thank you. I absolutely agree and this is one of my big concerns. The 42 CFR 411.46 code says, "If a settlement appears to represent an attempt to shift to Medicare the responsibility for payment of medical expenses for the treatment of a work-related condition, the settlement will not be recognized." The code goes on to give an example saying if settlement documents attempt to release the IC from liability for medical expenses for a particular condition "even though the facts show that the condition is work-related, Medicare will not pay for treatment of that condition." It sounds to me that CMS would defer to the body parts previously listed in the approved MSA proposal.

Even worse, in other places (such as the WCMSA Reference Guide) there are statements that if Medicare's interests are not considered, Medicare may refuse to pay for future medical expenses related to the work injury until the ENTIRE settlement is exhausted. I certainly do not want my other money in the settlement to have to be used up to cover what the MSA is intended to pay!

The scary part is that my attorney seemed to be encouraging me to agree with the defense attorney's plan, but I said I did not agree. Thank you for helping me feel confident that my gut feeling to disagree with this was correct.

(01-30-2018, 05:34 PM)1171 Wrote: . what happens to the value of your settlement if CMS does not exclude that treatment?
As mentioned above, I'd think CMS/Medicare could require me to exhaust my entire settlement (not just the MSA amount) before they'd pay for care related to the work injury.

(01-30-2018, 05:34 PM)1171 Wrote: 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?
Thanks! These are excellent points to bring up if the IC isn't willing to correct the body parts to match the approved MSA. I'd think the DA would start back-pedaling very quickly on their plan to switch body parts.
(01-30-2018, 05:34 PM)1171 Wrote: 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.

Thank you very much for confirming what I was thinking would likely happen. Now I feel assured of my thinking and know that I should not accept this "plan" of switching body parts as presented in the current documents.

I really appreciate your help!!
 
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#18
(01-31-2018, 07:29 PM)Seeking Help Wrote:
(01-31-2018, 02:33 AM)Shadow Wrote: I hear of people saying they can get coverage for a comp injury on a private policy ..I find it interesting people say that. When I look at the Evidences of Coverage for say a Blue Cross policy it contains a subrogation clause that precludes third party claims and the insured must notify the carrier that some one else holds iability for the medical bills within 60 days so the carrier can lien other claims. Such as a comp carrier. I suspect ( but i dont know for a fact ) that people are not being honest when having another insurance company pay medical bill that arose from a work injury. I was taught that no private insurance company is going to accepts liability for medicals that another hold liability for. I have just never seen it ..maybe I'm wrong. Typing is hard for me due to disability. I feel your frustration. Call a private medical insurer and ask .. I think the answer is going to be No ! or they will and maintain subrogation rights.

You make good points.  Thank you, Shadow.  I was thinking that group insurance from an employer would not exclude pre-existing conditions.  But the work injury would not just be pre-existing, it would also be a different insurer's liability, unless those body parts were truly and legitimately denied to be part of the work injury.

I'm pretty sure I have read in CMS documents that if a person with an MSA loses Medicare coverage they are still allowed/required to pay for the specific body parts out of the MSA.  That is, the MSA money is not frozen if a person loses Medicare coverage.  But as you've mentioned, if the MSA amount is inadequate it could run out before the person reaches retirement age when they're automatically eligible for Medicare.  

I feel quite confident my MSA amount will get me through until my full retirement age, or age 62 at least, but your cautions are very important, particularly for a younger worker to consider.

You are very welcome .

I always say pre -existing conditions must be accepted but not pre- existing claims . I hear people say they can get a work comp injury covered under private insurance . I've just never seen it . I always wondered if they are telling the truth to the provider. My wife has had Blue Shield and Blue Cross over the years .. both policies have subrogation clauses and must be notified with 60 days of anothers liability for covered services. If we could just C and R our claims , go to Hawaii and have our private Insurance pick it up that would just be wonderful . We'd all be so happy Smile My own Attorney said well your wifes insurance will pick up the medicals in your workers comp case . I said ok great ... just write me a letter to that effect so I can take it our private insurer and demand coverage. LOL. You sound very knowledgeable Seeking Help . Keep an eye on that lawyer . They make more money when you release medical and then they are done with you .
Good luck !
 
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#19
I,m glad you researched the CMS code in this issue; most do not. The very existence of such language shows that it's a common problem well recognized by CMS. I suggest you file a complaint directly with the head of the defense law firm with a copy to the president of the insurance carrier.
You are also entitled to file a complaint with the state bar. Whether your atty was complicit in this "misrepresentation"/lie I' ll leave to you.

It seemed obvious your atty was just as anxious as the carrier for you to accept the settlement as it was being sold to you or they would have raised questions similar to what I posted.
It's a common problem in low fee litigation like workers comp for attys to prioritize settlement over repeated court appearances and all the "extra" work that entails.
I was expressing my doubts that your atty would be willing put in the time for a trial and would rather pick up another client that offered a quicker turn around. The system prefers and incentivizes settlements often to the detriment of the worker.
These attys see each other much more often then then they see you. Low fee = lower client loyalty.
It's the nature of the beast and it needs to be factored in when making decisions.

The whole existence of the MSA process came about because of the rampant cost shifting engaged by the legal community especially as med treatment costs accelerated. It,s beyond the pale for them to corrupt the corrective measures right in face of the ethics oath each atty takes.
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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#20
(01-30-2018, 07:52 PM)Seeking Help Wrote: 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.

Please send us an email at boardadmin@workerscompensation.com and we can make the change – as long as the email you send it from matches what is on file. Thank you.
 
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