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P&S with restrictions but no disability rating. What?
#81
(05-26-2017, 08:23 PM)California_Help Wrote:
(05-24-2017, 01:25 AM)1 Hurt nurse Wrote: Yeah, my doc will send it but utilization review has already denied all recommended treatment.
Uphill battle especially now that they have an attorney. This system is so difficult

Hurt nurse make sure your doctor is sending in his requests on the correct form called an RFA. The link I provided you previously has those forms if you want to print to give to your doctor.

California workers compensation follows MTUS guidelines. ACOEM and ODG. If you want something approved you really need to submit with those guidelines or if your condition or request goes outside of those guidelines, you can submit others by searching internet for example. You as a patient can also submit a UR appeal to the UR company directly addressing the reasons for the denial. There is usually a 5-10 day deadline for this. If you need help with this I can help. The MTUS guidelines are also on the states webpage. What I have done is research guidelines needed and gently hand them to my doctor and say if this can help...and it usually does.

You can shop around for an attorney to take your case. I do not think they would take 15% but that would be up to a judge.

Being out of state it is important to close out your medical if all of your medical treatment is being denied, in my opinion. You should be submitting receipts for reimbursement. There is mileage forms on the states website and I use them and black out the mileage info. I number each receipt and tape them to a piece if typing paper. You should ask your doctors office for a copy of his report for each visit and attach it as well.

Again, if he is not sending in the RFA form they can legally ignore his treatment requests. I can show you how I do internal UR appeals or gather appropriate rational to make a strong request using treatment guidelines. Most (not all) of my appeals go in my favor and some doctors are now using my system. If you need my help let me know.

It's like you read my mind. I so need your help on this.
 
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#82
I tried to edit my last post but was not able to. This is updated with some links.
Let me know when I can help you. I will send you a private message with some additional info on how to make solid requests and/or appeal UR denials. Again if the RFA form is not being used they can legally deny it. It is very easy to fill out.


Hurt nurse make sure your doctor is sending in his requests on the correct form called an RFA. The link I provided you previously has those forms if you want to print to give to your doctor.

California workers compensation follows MTUS guidelines. ACOEM and ODG. If you want something approved you really need to submit with those guidelines or if your condition or request goes outside of those guidelines, you can submit others by searching internet for example. You as a patient can also submit a UR appeal to the UR company directly addressing the reasons for the denial. There is usually a 5-10 day deadline for this. If you need help with this I can help. The MTUS guidelines are also on the states webpage. What I have done is research guidelines needed and gently hand them to my doctor and say if this can help...and it usually does.

Here is link to MTUS guidelines.
https://www.dir.ca.gov/dwc/mtus/mtus_reg...lines.html

Here is link to MTUS chronic pain guidelines.
https://www.dir.ca.gov/dwc/DWCPropRegs/M...icPain.htm

There is a link on the internet to free ODG guidelines (I have to look for it).

You can buy ACOEM 2nd edition guidelines book.

I have used other treatment guidelines if the request or the patients condition fall outside of these guidelines for example Medicare guidelines, Aetna guidelines and peer review studies. This I got from google search. If you want to get fancy you could go to a medical library and I am sure find more. I have gotten so good at it that I have used these to appeal a few private insurance denials.

I also have a system of look up for guidelines and rational to approve requests I do not want to share on public website but will send in a private message if you need it.

You can shop around for an attorney to take your case. I do not think they would take 15% but that would be up to a judge.

Being out of state it is important in my opinion to close out your medical if all of your medical treatment is being denied. You should be submitting receipts for reimbursement. There are mileage forms on the states website and I use them and black out the mileage info and write in reimbursement info. I number each receipt and tape them to a piece if typing paper and attach. You should ask your doctors office for a copy of his report for each visit and attach it as well as your insurance company stated that is needed to request reimbursement. I assume they are not paying your doctor? Have they paid for any treatment, medications etc?

Again, if he is not sending in the RFA form they can legally ignore his treatment requests. I can show you how I do internal UR appeals or gather appropriate rational to make a strong request using treatment guidelines. Most (not all) of my appeals go in my favor and some doctors are now using my system. If you need my help let me know.
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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#83
I am having difficulty sending you a private message. I will try back later.
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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#84
Hi,
Please try the pm again.
The insurance company reimbursed everything until the attorney took over for them in February. Now nothing. Will give these forms to my doctor. All help in this regard sincerely appreciated. We're behind the 8-ball and defense knows it. Really hoping to settle medical but need some leverage.
Best,
Hurt nurse
 
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#85
Something appears to be wrong with private messaging. I cannot even access my messages. 1171 are you able to get to your private messages?
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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#86
(05-29-2017, 11:08 PM)1 Hurt nurse Wrote: Hi,
Please try the pm again.
The insurance company reimbursed everything until the attorney took over for them in February. Now nothing. Will give these forms to my doctor. All help in this regard sincerely appreciated. We're behind the 8-ball and defense knows it. Really hoping to settle medical but need some leverage.
Best,
Hurt nurse

It is good your doctor has the correct forms, but you may need to look up medical treatment guidelines to help. Also, if your doctor has requested something that has been denied by UR within the last 12 months, the only way to get it approved before the 12 month waiting period is to have a change in condition or change in material facts known. There is a box on the PR-4 that needs to be checked off if this was the case. So for example if your doctor requested something and it was denied for example patients has not attempted physical therapy first, and in fact you have done PT but those records were not included in the request or included in an appeal, that is a change in material facts known to the UR reviewer. Does this make sense to you?

Please review one of your past UR denials, on the last few pages it should state how to do an internal UR appeal with the UR company and how many days after the date of the denial letter you have. Usually it is 5-10 days. This is different than requesting an IMR review by Maximus, which you have 30 days from the denial date. In my opinion it is easier to get things approved through internal UR appeal process than IMR that has 95% denial rate.

If there is a treatment or test you really need perhaps it would be best to research the medical treatment guidelines before your doctor request it. I can help you with that but do not really want to do it on public forum. I do not want insurance industry to know my mojo. Hopefully pm will work soon.
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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#87
I am having problems with private messages and also cannot access the regular forum to alert the moderator, or even to post a new post on this site and why there may not be new posts on this site.
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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#88
Yup. The updates and fixes are coming very slow. The site has been in "excuse my dust" mode for last couple years. If it takes any longer it may be too dead to matter. i'm just about done with it myself; just too broken to hang around waiting.
I'm thinking I'll just post a few of the most helpful links for those that may wander by and hope they help.
This is one of the only sites not run by a law firm that refers everyone with question to an atty.
Admin/ Bob said a couple weeks ago to be patient as they are working on it........
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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#89
(05-30-2017, 06:13 PM)1171 Wrote: Yup. The updates and fixes are coming very slow. The site has been in "excuse my dust" mode for last couple years. If it takes any longer it may be too dead to matter. i'm just about done with it myself; just too broken to hang around waiting.
I'm thinking I'll just post a few of the most helpful links for those that may wander by and hope they help.
This is one of the only sites not run by a law firm that refers everyone with question to an atty.
Admin/ Bob said a couple weeks ago to be patient as they are working on it........

OK.

Hurt nurse. I still cannot send you a pm.

If there is something specific your doctor is requesting let me know and we can start working on treatment guidelines.
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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#90
Thanks! I tried to PM you my email address but I don't think it went through.
The only things I see on the treatment guidelines for lower back and neck injuries are acupuncture and opioids. Seems very bleak.
The treatments that are helping me are rolfing, pilates and chiropractic. They were specifically recommended by my QME. I can start seeing an acupuncturist if you think they will cover it. Do you think there is a way to get my current treatments covered? I am happy to copy and paste my last QME report if that would help.
 
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