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medical release/buyout? and/ or fight for medical ongoing - Printable Version

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medical release/buyout? and/ or fight for medical ongoing - sahshah - 04-06-2015

I settled with award/stipulations thru a lawyer that agreed to settle me out as the stress from wc for over 10 years was becoming unbearable and life-altering. My initial TV atttorneys told me I was a Pandora's box due to the amount of injuries I had suffered and issues with the numerous surgeries, appx, 14, including 1 c5-6 fusion and filed to be released from me due to irreconcilable issues, which I sent my opinion but did not fight their request so was without representation for appx 5 years. I ssaw AME appx 12 times and his MMI report was not completed as he had ordered all new MRI's, EMGs, xrays but did not review these before writing his final report, I was more interested in my health improvement than losing my mind. The award included $66k, 56%pd as in 87 had a 46% pd on left knee when younger and a different position. Then in 12/13 my new atty and defense met to agree what the judge approved 1/6/14. They refused to provide an accounting as they did not pay the amount awarded minus my pd their balance is $8700 proven to the judge by both attorneys before he signed the award. Penalties and fees were in the award as well as medical agreed by the AME to include my PTP, his decisions, my pain mgmt., meds, injections, acupuncture, 3 years of 20 visits of swimming a year of which I received only 10 visits 11 months after the award and now am being denied everything including my very potent pain patch, had I not had my private insurance the WC examiner who has made inappropriate calls to me re; my meds and personal things as well as to my doctor's offices, I would be in a cold turkey withdrawal and serious medical problems would increase and not receiving letters for reason of denial for this prescription has not been received by anyone, just the pharmacy copy of denial from a drug co used by wc, I informed my atty. My atty mentioned a medical release and I discovered it did not involve the judge and being 61, with looming spinal surgery due to further disabling degeneration and cervical issues worsening, being in a constant battle for what I was awarded is not worth the fight, yet I need to know what to provide my atty and what to really say to him to get a real explanation of the release and the agreement of the amount. I know there is no set 5 of money, I need peace not war, can I still go to trial as they have not complied with the award. I know I am supposed to receive the interest and penalties for my underpayment, I'm lost at this point as atty seems to not want to explain to me, just do it, which is fine, but I need to know what's happening and how to best do this as the judge is not involved. They dropped 3 of the 4 cases and made them 1.


RE: medical release/buyout? and/ or fight for medical ongoing - 1171 - 04-06-2015

it depends on the state laws that govern your claim.
http://www.workerscompensation.com/forums/general/showthread.php?tid=10146

generally any dispute over benefits paid or owing can be taken to the comp court.

I'm not sure I totally understood your question.
you want an explanation of benefits paid and those to be settled and your attys are not giving it to you?

if your atty is not providing you an explanation have repeated requests, then they decided they are not going to. there are no magic words that will make your atty understand what you want and provide it if they have choosen not to.
you can file a complaint with your states' atty ethics organization.
if you are not getting the representation you want, you can change attys at any time or represent yourself.
if you think you have a problem making yourself understood, you might have a friend or relative talk to your attys with you. sometimes a third person can clarify misunderstandings between people.





RE: medical release/buyout? and/ or fight for medical ongoing - sahshah - 04-07-2015

Excuse me, I wrote well before the neuro issues began worsening. Atty did file for my underpayment the defense refused to provide additional accounting for or answer at all, we go to court for that Monday. When I spoke with my atty he mentioned a medical release agreement may be possible but did not explain too me that it is done outside of the judge. Wc has been denying many requests, I have an excellent PTP and his staff that do everything they can. I do not receive my copies of denials and reasons for denials, nor have I received a written explanation from UR or claims examiner, only pharmacy provider as to why wc stopped paying for meds I have had since injuries. I do not like all the stress and the new claims examiners that are denying everything and not following protocol. I would like to be medically released but need to know what is the best way to do that. I will have another meeting with atty after the underpayment hearing about my meds and other stipulated medical in the award, as well as no denial copies and discuss the bargaining that would go on between us and defense. I was looking for input on anyone experiencing a medical release after "lifetime" medical awarded in California. thank you, sincerely for your opinion.


RE: medical release/buyout? and/ or fight for medical ongoing - 1171 - 04-07-2015

to settle future medical benefits you may need a Medicare SetAside Agreement:
"The claimant is a Medicare beneficiary and the total settlement amount is greater than $25,000.00; or
The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00


more on set asides here
http://www.cms.gov/Medicare/Coordination-of-Benefits/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSAP-Overview.html

if you expect to use Medicare in the future for any of the comp injuries settled, you will need their approval for the settlement amount.
many times an independent agency is asked to prepare a Life Care plan to accurately identify all potential medical costs.

even though the settlement is negotiated between the parties, the court will have to approve it to be final.




RE: medical release/buyout? and/ or fight for medical ongoing - sahshah - 04-07-2015

Medicare elig eff 10-1-18. Stip/award signed by judge 1-6-14, although not complied with we go to court 4-13-15 for underpayment due with penalties, interest fees as stipulated as well, medicare would not be involved. Is there any other info about the buy out I should be a part of? Obtain more info for atty from treating doctors. is it better than fighting for stipulated and AME agreed treatments not $200k, not including any other body arts. What would a reasonable bargaining amount start with? Thank you very much.


RE: medical release/buyout? and/ or fight for medical ongoing - 1171 - 04-07-2015

I'm afraid utilization review is going to be part of on-going comp medical benefits for a long time despite the opinion of your treating doctor or the AME. the UR process has final say as to what treatment you get.

to accurately assess your future medical costs and prepare for negotiating a buyout (Compromise & Release), you nedd to develop a range of probable costs from low (optimistic) to high ( pessimistic) view.
the final amount should be somewhere in between.
since your current benefits are "life time" it's practical to identify your yearly maintenance medical needs (low to high) and multiply by your life expectancy.
then you add in big ticket items and/or one-time costs like surgeries, hospitalizations, nursing, etc -- again a low to high range.

once you have a range that seems to include most eventualities you need to reduce it to it's present value.
$10K needed 20 years from now is worth substantially less in todays $$.


you need to go over your future medical needs with your doctor to make sure you cover everything.
you also should be reviewing a history of the carriers paid medical costs to get an idea of what things are worth.

this process can be complicated but should be substantially what your atty may do.

here are some links that might help
http://www.claimspages.com/tools/value-of-money/
http://www.lifecarewriter.com/sample.pdf



RE: medical release/buyout? and/ or fight for medical ongoing - sahshah - 04-07-2015

I truly, sincerely appreciate your response. It gave me what I can do with clarity and simplicity, yet , I know is not simple. May I ask in reviewing the history of the carriers paid medical costs, is that what WC has paid since they have cared for me in 2003 to present and with the # of major surgeries I've had, is that info in a certain case info and would I need to use all 4 case #'s that were not combined until the stip/award or is it the amount they pay for what I may need in the future? Thank you.


RE: medical release/buyout? and/ or fight for medical ongoing - 1171 - 04-07-2015

yes
paid costs are the amounts & bills that have accumulated from the beginning of your claim until now.
they are not going to share with you or your atty what they estimate your future medical might be.


RE: medical release/buyout? and/ or fight for medical ongoing - sahshah - 04-07-2015

Are the amounts they have paid for the last 12 years available through them, under all 4 case#'s or I would have to request from as many provider's that would possibly have the info as their retention period of billing is limited, I believe?


RE:denial of meds n procedures CALIF - sahshah - 04-07-2015

When we settled on 1/6/14 with open medical and recommendations from the AME as to my ongoing treatment stated in the stipulations and now the new insurance co and examiner, have refused payment of my potent pain patch of 12 years, without I would be in hospital for withdrawal and other medical issues threatened, even though the pain mgmt. dr wrote a letter directly to the examiner as she had made inappropriate statements to me on the phone regarding my pain meds, my private insurance is paying them and the examiner will not send a written denial for appeal, I have only my pharmacy's copy of denial by wc thru the drug co used for WC prescrips. My PTP is appealing the denial of any more than the 10 visits they gave me 11 months after award 3 years of 20 visits a year aquatherapy, acupuncture with medical proof of improvement, 20 PT visits, injections, meds, and treatment decisions from my PTP, pain mgmt. and spine surgeon I thought I was awarded but is it right that the AME, I saw at least a dozen times, recommendations do not really mean anything, although written in the award signed by the judge? Can they deny the one med left they pay for without reason and as my insurance has covered it so I do not go into cold turkey withdrawal time passes and atty believes let my insurance pay and work on the medical buyout when the issue is serious and no written denial received, the more denied and less fought for allows them to sweep me under the rug and would seem to decrease my future medical as my PPO ins has paid for other medically necessary procedures on my WC covered body parts, leaving me owing and in collections? I have a PPO which as my medical insurance I turn to when an award is not honored, is that wrong? Do I tell them or simply take care of myself, making as many payment arrangements as posible as WC is a non-caring entity and will say and do what they want? I can't force my attorney to do something he doesn't want when I asked him to help me settle after years of no representation, going through healing from multiple surgeries and we are still fighting to get the underpayment they owe me, why would he argue over one prescription, they used to pay for 4 and AME/PTP recommended procedures I am in need of to have some type of life which the quality of has decreased egregiously?