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Open medical question
#1
If you settle your case with open medical how does your medicines normally get handled? I'm told sometimes they will give you a card that tells the pharmacy they will get paid.

Just some background still working getting this settled and I will have open medical. Trouble is they have not paid my pharmacy since Feb 2013 so I'm wondering why my lawyer thinks they are going to pay anything after we settle
 
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#2
(01-09-2015, 03:50 PM)Manley2 Wrote: If you settle your case with open medical how does your medicines normally get handled? I'm told sometimes they will give you a card that tells the pharmacy they will get paid.

Just some background still working getting this settled and I will have open medical. Trouble is they have not paid my pharmacy since Feb 2013 so I'm wondering why my lawyer thinks they are going to pay anything after we settle

I did not settle with open medical but I feel the Insurance Company would give you a Insurance card to pay for your prescriptions and possibly your medical needs. That is what I had for 10+ years of being on Workers Comp. in the state of Louisiana.

I settled with a compromise and release meaning I get a certain dollar amount for 28 years(my determined life span) to pay for my medical and prescription needs and I also received a Indemnity or Cash settlement. I am PTD and was given this final diagnosis by the WC Doctor on my 4th trip to him.

Settling with open medical was not a option for me. The IC would not settle unless we completely severed ties with each other.

We had a mediation in May 2009 and finally settled on the MSA amount after 3 years AND YES you have the right to overlook your MSA BEFORE it is sent to CMS for there approval or disapproval. You have to cover your butt here because Medicare will approve the MSA and it will not contain what you need. My Attorney and I accepted the 2009 settlement bases on the contengency that we got to approve the MSA amount BEFORE Goulds and Lamb sent it to CMS.

I am glad I have nothing to do with Gallagher Bassett anymore. As long as I follow what Medicare would pay for, I am good. I send in a Account expenditure every year to CMS. It is a piece of cake.

You settling with open medical gives the IC the right to turn down medical procedures, prescription drugs etc. because they are still in control. That is why I am so glad I severed ties with the IC.

I was in the WC Areana for 10+ years. They never missed a paycheck or failed to pay for my medical except in the beginning when they denied my surgery for 3 years......
Had a car wreck in 2003 while on the job. Settled in Jan. 2012 with Indemnity pay and a MSA. Approved for SSDI in March 2006. Was declared PTD at IME in 2009. Took approx 3 years to finalize the WC settlement. ALWAYS use spread language when settling Indemnity or SSA will nail your fanny.
 
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#3
For those of you that don't know what "spread language is, ( I didn't either) this is what I found.

Workers’ Comp 101—What is “Social Security Spread Language?”
by Eugene Keefe on 03/27/12
We keep getting asked and wanted to let WC newbies across the U.S. know what this concept might be. In most situations, we tell WC claims adjusters to allow the other side to provide spread language for your consideration and use.

The main concept is a lump sum workers’ compensation settlement in all states may reduce dollar-for-dollar any ongoing Social Security disability benefit payments being paid to the injured worker. Basically, if the injured worker gets a whopping settlement, they are going to lose part or all of their right to ongoing Social Security payments.

For reasons we aren’t sure of, the Federal Government allows injured workers and their attorneys to magically “spread” the lump sum over their lifetimes to avoid the setoff or reduction in benefits owed. To minimize or legally “circumvent” offset of Social Security disability benefits, a workers’ comp settlement agreement must contain language that spreads out payments over time. Absent this “spread language” in the workers’ comp agreement, the lump sum payment is certain reduce Social Security benefits to which the claimant is otherwise entitled.

For example, let’s say a 50-year-old worker injures their rotator cuff. At age 52, the worker suffers a disabling heart attack that keeps them from working. Two years later, the worker obtains a Social Security disability award of $1,000 per month. The worker then settles the shoulder claim for $50,000.

Assume further the disabled worker’s lump sum workers’ comp settlement agreement did not contain spread language. If that occurs, the Social Security Administration will set off the entire lump sum settlement of $50,000 against the $1,000 monthly Social Security benefits. As a result, the disabled worker is precluded from obtaining Social Security disability benefits for the 50 months he was entitled to receive those benefits. This would be true despite the fact the two medical issues are completely unrelated.

To avoid the offset, the workers’ compensation settlement agreement has to include language spreading out the $50,000 payment over the worker’s life expectancy. For example, at age 52, the worker has 34-year life expectancy. The workers’ comp settlement of $50,000 could have been spread out over that entire lifespan in monthly payments of approximately $122.00. Accordingly, subsequent Social Security monthly benefits of $1,000 would only have been reduced to $878.00.

Below is sample language to include in a workers’ compensation settlement agreement that spreads out the one-time payment of lump sum WC benefits over time:

After payment of attorney’s fees and costs, Petitioner will receive a net amount of $__________. This is for a permanent impairment that will affect the claimant for the rest of their life. The mortality table indicates Petitioner at age _______ has a life expectancy of _______ years or _________ months. The amortized monthly net benefit is _________ per month. This represents future income replacement. This paragraph is intended for federal Social Security purposes only.

More information can be found on the Social Security Administration’s website including http://www.socialsecurity.gov/OP_Home/ha...-0504.html. We are happy to assist if you have questions or concerns about these and related issues. We appreciate your thoughts and comments. Please do not hesitate to post them on our award-winning blog.

I hope 1171 will chime in, and let us all know if this is right, and if it applies to us.
 
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#4
I don't get a choice but open medical. The set-a-side would be too much for them and they can't be ordered to do the set-a-side. And my lawyer knows about the spread language so I hope he gets it worded right.

Why I'm asking about the meds is my pharmacy tells me that once I settle without this card they will only bill medicare for my meds and submit it to WC and maybe I get my co-pay back. Just can't see medicare liking this. My meds run around $3,000 a month
 
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#5
carriers are free to make whatever medical benefit payment options they choose. whether they use a third party service, some kind of pre-authorized card system of just standard billing. the law doesn't require a single method.
make sure your atty will be willing to continue representing you once he gets paid from the disability settlement; often times once the fee is gone so is your legal help.
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
I agree with 1171. Not only that but, I've never heard of you having too sale your FM. this is something that has to be agreed to by both sides. Don't know if it's the same where your from, but in CA. both parties have to agree.
 
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#7
1171 he has said he would fight anything they don't want to pay for and not charge me, he is suppose to put that is writing. Trouble there is I asked what happens when he retires and he claimed I would have no problem getting another lawyer willing to take it because there is money to be made. Right now I have another one that would be willing to help if need be but you never know until it comes time to jump in and do it.

Just talked to him on the phone and he said if a card to cover medical is what I need to sign I will have it. Guessing this is still something they could take back down the road at sometime so still not buying into it all.
 
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#8
Just doesn't seem like it they have been paying for meds that they could ever not pay in the future if they have aggreed to open medical and it is something they have been paying for. Now I could understand if a doctor wanted to change a med or add something they could want to make sure it is needed or how ever you would want to say it. Now a few months back now I did get in touch with my local US Congressman and his office sent paperwork to them saying they needed to pay back medicare for my bills so not sure if this would help down the road
 
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#9
So once they decide this all and I have open medical who on the companies side manages the claims? Maybe a better way to put it is who says yes or no to something being covered?

Not sure how things like the RF I get will go. I've had it pretty regular for the last 7 or 8 years so I'm not sure what they would argue when I have the next treatment. I'm thinking they are going to go back to deny the treatment an hope medicare picks it up and they don't ever have to pay them back
 
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#10
Like always the carrier or the comp court if there is a dispute.
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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