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IMR
#1
California Claim

Ok, So I now have a totally irrational piece of garbage IMR decision. Just ridiculous how these reviewers are tossing around portions of the MTUS and so on.

Actually the ODG, MTUS , ACOEM, Chronic pain regulations do not even apply to complex patients.

I am considering a request to AA to file with the WCAB . Of course this is a big problem as the AA absolutely doesn't want to do this.h

Oh yea .. I am going to call Medicare ( secondary insurance ) and ask them to pick up the IMR denial. Those of you interested .. I am willing to share . They might tell me to pound sand... I don't know ..) Maybe they will pay for the treatment an I can rejoice. Let you know what happens . Might be going to the Beach Smile

How does one fight this ?

Any Ideas ?

Thankyou

Shadow
 
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#2
(02-11-2018, 05:01 AM)Shadow Wrote: California Claim

Ok, So I now have a totally irrational piece of garbage IMR decision. Just ridiculous how these reviewers are tossing around portions of the MTUS and so on.

Actually the ODG, MTUS , ACOEM, Chronic pain regulations do not even apply to complex patients.

I am considering a request to AA to file with the WCAB . Of course this is a big problem as the AA absolutely doesn't want to do this.h

Oh yea .. I am going to call Medicare ( secondary insurance ) and ask them to pick up the IMR denial. Those of you interested .. I am willing to share . They might tell me to pound sand... I don't know ..) Maybe they will pay for the treatment an I can rejoice. Let you know what happens . Might be going to the Beach Smile

How does one fight this ?

Any Ideas ?

Thankyou

Shadow

Nor sure if you can under what you described. In this link it mentions 5 reasons why an IMR can be disputed. Also, if you have a change in condition or material facts known this may allow your doctor to make another request through UR before waiting 12 months..

If your condition did not fall under those guidelines, then your doctor needed to submit appropriate guidelines to approve. UR and IMR will use boilerplate guidelines as a means to deny even if it is a complex condition.


https://www.lexisnexis.com/legalnewsroom...ected=true
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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#3
(02-11-2018, 05:01 AM)Shadow Wrote: California Claim

Ok, So I now have a totally irrational piece of garbage IMR decision. Just ridiculous how these reviewers are tossing around portions of the MTUS and so on.

Actually the ODG, MTUS , ACOEM, Chronic pain regulations do not even apply to complex patients.

I am considering a request to AA to file with the WCAB . Of course this is a big problem as the AA absolutely doesn't want to do this.h

Oh yea .. I am going to call Medicare ( secondary insurance ) and ask them to pick up the IMR denial. Those of you interested .. I am willing to share . They might tell me to pound sand... I don't know ..) Maybe they will pay for the treatment an I can rejoice. Let you know what happens . Might be going to the Beach Smile

How does one fight this ?

Any Ideas ?

Thankyou

Shadow

With an IMR denial in hand you should be able to get care for that denied service through Medicare. You might be better off getting the care outside work comp anyway. IMO, it's not a bad idea to call Medicare BCRC first to get their feedback on the process. They should tell you that they will make conditional payments when you already have a written denial.

I'm no pro, but I would suggest you call whatever doctor or facility you are interested in seeing and ask to talk to their billing person. Or maybe even better to first call a couple of offices/facilities you are less interested in, to get a feel for how they react and what questions they will ask.

I suggest you find out from the billing person if the office is familiar with Medicare Conditional Payments and tell them you have a written denial from work comp in hand. I suspect the billing people are more apt to understand what you are wanting than a person who schedules appointments.

If they are knowledgeable about Conditional Payments and are willing to schedule you, then you should be in good shape. If they aren't familiar with Medicare Conditional Payments then you may need to explain the process to them. I've described it like a car accident where other person is at fault but their insurance company is stalling. My auto insurance is obligated to take care of the problem for me and can seek reimbursement by the other person's auto insurance. That often helps the billing person to understand if they didn't already know.

Let us know how it goes.
 
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#4
Depending on all the particulars, you might also think about whether you want to choose a Medicare doctor who is/ is not familiar with work comp, and also if you want to go to one who is/is not also on your work comp insurance carrier's MPN.

One thing I wondered, is if a doctor who is in my MPN but also accepts Medicare might still be more loyal to the IC than if I chose a doctor who is quite removed from work comp altogether. My work comp insurance likes to kick doctors off the MPN if they try to help an IW, particularly one with an old claim. Or maybe a doctor who knows about work comp but is not in your MPN would be the most helpful in providing whatever care you are seeking. You would be the one to weigh advantages and disadvantages depending on what service/treatment the IMR denied.
 
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#5
Utilization review & mutus controls what treatment is allowed much more then the choice of physician.
http://www.dir.ca.gov/dwc/MTUS/MTUS.html
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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#6
deleted a duplicate post. I thought I could make a simple edit.
 
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#7
(02-12-2018, 03:34 PM)1171 Wrote: Utilization review & mutus controls what treatment is allowed much more then the choice of physician.
http://www.dir.ca.gov/dwc/MTUS/MTUS.html

Sorry if I wasn't clear. I thought my 2nd post was going to append to my first post.

I was meaning if Shadow decides to use the IMR denial to get treatment through Medicare as a Conditional Payment, that it might be good to think about pros and cons of whomever/wherever he/she chooses to go to for the denied treatment.

Since we don't know what the IMR denied, I could only give a general suggestion of things to potentially keep in mind when choosing a provider for that treatment or service.
 
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#8
Yes, that clarifies it.
I agree. Physician choice is important when treating outside of California comp.
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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#9
Found this : https://www.lexisnexis.com/legalnewsroom...ected=true
 
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