[Lenaye]

My husband has a wc case in CA that is over 10 years old. We told the lawyer we wanted to settle because wc denies all treatment (including phys ther) except pain killers. They even had to go to court to get permission for an MRI. Lawyer notified us this evening that wc will not agree to a settlement because it is too expensive for them, the amount Medicare wants is too high. I think it was estimated to be about 180K. What recourse do we have? He needs treatment and wc has us locked into this "do nothing/deny everything cycle.

[1171]

there is no alternative to using the legal system to settle disputes.
if you have other health insurance or get coverage under the affordable care act, they might cover it.
of course the last resort for those without coverage or denied care is to pay for it yourself.

[Manley2]

Not think you are a lone. For 3 former employees with the company we worked for they are not going to settle with us because the set-a-side is too much. Not sure of the amounts but they are higher then the $180k. They have tried to cut off things like meds and treatments and that is where my lawyer steps in. Now one thing to remember when we have to go this route nothing works out over night but unless your going seek someone else to cover it or pay out of pocket you don't have much choice. One of the things they like to do is give you this hassle in hopes you will do something else and safe them the money. Good luck and I hope you can get the care he needs

[Katiedid]

(11-20-2013, 10:21 AM)Manley2 Wrote: Not think you are a lone. For 3 former employees with the company we worked for they are not going to settle with us because the set-a-side is too much. Not sure of the amounts but they are higher then the $180k. They have tried to cut off things like meds and treatments and that is where my lawyer steps in. Now one thing to remember when we have to go this route nothing works out over night but unless your going seek someone else to cover it or pay out of pocket you don't have much choice. One of the things they like to do is give you this hassle in hopes you will do something else and safe them the money. Good luck and I hope you can get the care he needs

How does one find out if a set asside is too high. I also have SSDI and live in Oregon.

[1171]

(03-14-2016, 09:17 PM)Katiedid Wrote: How does one find out if a set asside is too high. I also have SSDI and live in Oregon.

it's only too high if it's more then the carrier will pay.
it depends on the situation but you have a third party evalutor review the medical usage data/treatment plan and come up with a CMS setaside figure. that estimate is sent to Medicare. if they accept it then it's up to the carrier to decide if they want to include that amount in the settlement.

[Katiedid]

My Doc est 31k with his and hospital plus P T. Settlement is offered at 21k after attorney fee. How do I know if 3rd party has reviwed or not. Also what is CMS please ? Thank you from Oregon.

[1171]

it appears as though you might not qualify for a set aside agreement.
more here:
https://www.cms.gov/Medicare/Coordinatio...rview.html
you might want to start a new thread since we are no longer responding to original poster.

[California_Help]

I agree with 1171 as your settlement amount may be lower than the threshold to need to have a MSA or a 3rd party to review it (25k I think).  You would know if you had a 3rd party review it because you would have signed a document that allows this with a release of records.