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CA new laws pertaining to Medication/Treatment - Printable Version

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CA new laws pertaining to Medication/Treatment - Babebahn - 01-04-2017

I have noticed since July 2016, that my work comp carrier has been questioning every treatment plan.  Today I received a letter from "Peer Review" stating Medication will be filled until "WEANED" then all  Medication will be denied... WTH!
So I called my Adjuster who stated there's new laws in California for Patients on "Pain Management  She said I needed to contact my Attorney and discuss the new laws and how they will affect me, since my Case is Closed.  She also told me to Fill Out the "application for Independent Medical Review Form IMR" and get my medical records as soon as possible. I have 10 calendar days... The papers are dated 12/20/2016 I just got the today!  Thank goodness I called my Adjuster to tell her I just received them... Now let the games begin!
So researching online I discovered that Yes there are new laws effective July 2016 pertaining to Medication Pain Management.  153 pages worth, interesting read but makes your head spin! 
My question is If my Attorney Office is saying "We have settled your claim (Lifetime Medical w/ C&R) and no longer received adequate medical information we cannot assist you in this matter... but I thought he was suppose to continue to represent me should any issues comes up such as this?
Secondly, If my pain management doctors are not available to answer questions from Peer Review when they call, what am I suppose to do?
I honestly feel that now that my case is settled I am left drowning trying to figure how to get adequate treatment, medication and referrals.  this is not was my attorney told me when we were settling my case! He said I would always be treated with no problems!


RE: CA new laws pertaining to Medication/Treatment - 1171 - 01-05-2017

you can try to negotiate a settlement of your future medical treatment. if you are medicare eligible they will have to sign off on the amount.
you can also contact the state legislator for your district and complain about the change in laws.


RE: CA new laws pertaining to Medication/Treatment - Babebahn - 01-05-2017

(01-05-2017, 12:03 AM)1171 Wrote: you can try to negotiate a settlement of your future medical treatment. if you are medicare eligible they will have to sign off on the amount.
you can also contact the state legislator for your district and complain about the change in laws.

I have a call into my attorneys office, left message with his assistant to discuss "reopening my claim" "getting treatment" and "how to move forward with the new future medical laws/issues". Since my case was settled back in 2006, I know I still have rights pertaining to my current case settlement... on another website workers-compensation.com/lawyers I read that there is a way to prove that my condition has gotten worse, I need surgery again which will cause more debilitating side effects including vocal cord damage and the inability to move my neck like a normal person.
Btw, I do have Medicare and on SSDI
Thank you for your advise in contact the State Legislator, I just might do so... thanks 1171 ?


RE: CA new laws pertaining to Medication/Treatment - California_Help - 01-06-2017

Read the entire Utilization review denial. You should file for an IMR and it has the form on how to do this. I recommend to black out your attorney's info on the form because MAXIMUS will send your attorney info on when you can submit records. Let me know if you have any questions.

There should also be directions about how to do an internal UR appeal. You usually have around 5-10 days after the date of the UR denial to do this. If it states your doctor was not available to do the peer to peer call there is a away for him or you to appeal the denial. You can call your doctors office and ask if they will send in a UR internal appeal that addresses the reasons for the denial. If they will not do it then you can and I can walk you through how to do this. You have a much better chance to get this overturned through the utilization review company rather than IMR. Try to get your doctor to appeal this through UR ASAP and if that does not happen you have 30 days to send in the request for IMR.

You are lucky this is the first time they are doing this to you. Some have to appeal these denials almost monthly. Also, just because they wrote rational that states your medications are not warranted, it does not mean that is accurate. It sounds like the UR doctor wanted some additional information and why he stated he attempted a peer to peer. UR does not have your entire medical file and this denial may be based upon lack of records. I have no idea. Try not to panic, if this gets denied by work comp and you have Medicare, Medicare should pay for it, but you will have co-pays.

I agree with 1171 and ask your attorney if he can ask for a settlement to close out the medical in your claim. Then you will have a medicare set aside and after that is gone use Medicare and not deal with this work comp BS. Your case should not be closed as your adjuster stated unless you closed out the medical in your case. I recommend going down to an I&A officer at your local WCAB if you have a lot of questions.

Ask your attorney of he is still representing you and if not ask him to send you your entire file. You may need it as it should contain your medical records. And if he is not representing you anymore all of your doctors should copy you on their reports. Find out what your situation is first.


RE: CA new laws pertaining to Medication/Treatment - Babebahn - 01-11-2017

(01-06-2017, 07:46 PM)California_Help Wrote: Read the entire Utilization review denial. You should file for an IMR and it has the form on how to do this. I recommend to black out your attorney's info on the form because MAXIMUS will send your attorney info on when you can submit records. Let me know if you have any questions.

There should also be directions about how to do an internal UR appeal. You usually have around 5-10 days after the date of the UR denial to do this. If it states your doctor was not available to do the peer to peer call there is a away for him or you to appeal the denial. You can call your doctors office and ask if they will send in a UR internal appeal that addresses the reasons for the denial. If they will not do it then you can and I can walk you through how to do this. You have a much better chance to get this overturned through the utilization review company rather than IMR. Try to get your doctor to appeal this through UR ASAP and if that does not happen you have 30 days to send in the request for IMR.

You are lucky this is the first time they are doing this to you. Some have to appeal these denials almost monthly. Also, just because they wrote rational that states your medications are not warranted, it does not mean that is accurate. It sounds like the UR doctor wanted some additional information and why he stated he attempted a peer to peer. UR does not have your entire medical file and this denial may be based upon lack of records. I have no idea. Try not to panic, if this gets denied by work comp and you have Medicare, Medicare should pay for it, but you will have co-pays.

I agree with 1171 and ask your attorney if he can ask for a settlement to close out the medical in your claim. Then you will have a medicare set aside and after that is gone use Medicare and not deal with this work comp BS. Your case should not be closed as your adjuster stated unless you closed out the medical in your case. I recommend going down to an I&A officer at your local WCAB if you have a lot of questions.

Ask your attorney of he is still representing you and if not ask him to send you your entire file. You may need it as it should contain your medical records. And if he is not representing you anymore all of your doctors should copy you on their reports. Find out what your situation is first.

1711 & California_Help So my attorneys assistant called, she said 1st and foremost, "You're case was settled in 2006 you had 5 years to re-open your case if you felt you were worse.  At this time, the only recourse you have is to try to get work comp to review again the medical necessity of medication, treatment and surgery. If they choose not to review or accept any of these then you need to go to your private insurance or Medicare for medical intervention. Since your case is closed we do not have your medical records even though our office receives updates from your physicians, we do not have the means or storage to accommodate all our clients medical records on our facility. When we receive a letter from any work comp companies, we forward it back to You or any clients with a letter stating that we will not be of assistance if the case is closed but we also include instructions as to how to proceed with Peer Review."  She then told me because my case is so old there's no attorney out there that will assist me at this point in time.  I asked if I could come in and speak to my Attorney and PAY for the appointment and she said Mr so and so is unavailable, and she also told me to ask my Drs office to stop sending update she to his office. I'm wondering if I should hang out at his office or at WCAB office and wait for him and let him know what's going on with his assistant. 
I told her Mr Attorney never told me I had a 5 yr window to reopen my case, he knew at the time of settlement that the surgeon was unable to complete my surgery because no Neurosurgeon or Orthopedist had ever done a 5-7 level fusion before, he also knew that during the surgery I had vocal cord damage and throat damage but never offered any recourse... So in my eyes my Attorney failed me! I even paid him an additional $10,000 per his request as a retainer should anything come up! 
I have an appt w/ my pain mgmt doctor to fill out the IMR and go from there... as far as settling out my Future Medical, how could/would I come up with a reasonable dollar figure to compensate for pending neck surgery, back procedures, and etc..?! 
I honestly feel like I'm backed into a corner ....
I appreciate all your help, advise, words of wisdom...
Sincerely... Shaking My Head


RE: CA new laws pertaining to Medication/Treatment - 1171 - 01-11-2017

It is illegal for an atty to accept any fee from a work comp client that has not been approved by the work comp court. (Or was the retainer included in the fee approved in the Award issued?) it's still unethical to ask for up front atty fee.

If he did so, you can file a complaint with the state bar.

Did you mention that you are interested in settling your claim to the atty office? They can collect an additional fee for a subsequent C&R after an Award.
Don,t take their word for getting a new atty. if you want to settle, talk to a few first.
Caaa.org.