Hello There, Guest! Login Register
Index    |     Search    |     Members    |     Help

Thread Rating:
  • 1 Vote(s) - 5 Average
  • 1
  • 2
  • 3
  • 4
  • 5
medical release/buyout? and/ or fight for medical ongoing
#11
I don't know what they have. most carriers file all the bills with the claim. whether they kept some with the separate claim numbers or put them in one master file is unknown.
every business has their own way of doing things.
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.
 
Reply
#12
they enact new laws every year; some new laws change the old laws.
california changed the old law with a utilization review law that controls medical treatment.
you can read up on it here
http://www.dir.ca.gov/dwc/MedicalUnit/imchp.html
http://www.dir.ca.gov/dwc/IMR.htm

you can contact your state legislator about the new laws.

generally the carrier contacts the doctor with treatment approvals, denials or requests for more information. the patient is not contacted.
if you want a copy of the correspondence between your doctors and the carrier and the utilization review unit have your atty request or subpoena them.

yes, the whole purpose of the new laws was to reduce injured workers' medical benefits and reduce the costs of comp insurance to the employers. the voters in califnornia wanted that and voted for legislators that would do it. write to your legislator and vote for politicians that support workers.

here is information on the new laws that the legislature passed
http://www.dir.ca.gov/dwc/SB863/SB863.htm
http://www.dir.ca.gov/dwc/sb863/SB863_Overview.htm

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.
 
Reply
#13
thank you very much for understanding and assisting me in understanding better..
 
Reply
#14
you are welcome.
comp is difficult enough for those who know what they are doing--it's almost impossible for those who are ill and suffering and unfamiliar with the level of bureaucracy involved.
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.
 
Reply
#15

Reading your issues I wonder if your PTP is not requesting your medications on the correct form. The laws changed in 2013 and he must make requests on a RFA form. If he does not, your adjuster can ignore him.

My advice is for you to do some research and legwork as to WHY your doctors requests are being ignored. I would ask your doctors office for copies of the RFA and fax/mail confirmation pages they sent to your claims adjuster. If they are requesting things correctly, I suggest providing your attorney with some of these records and write a letter stating these requests have been illegally ignored can you please file and expedited hearing. This is what I would do in your situation, but you really need to do a little research first.

AME's no longer have anything to do with treatment requests. Whatever your AME stated you should have in the future as far as medical treatment is no longer relevant. All treatment requests now have to be made on a RFA and may be subject to UR. The IMR paper review process is the only appeal process. These new laws can be difficult for this who settled with open medical and a report from an AME with the belief you will receive whatever the AME wrote for future treatment in the past.

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.
 
Reply
#16
Since I entered this forum a few days ago I feel less stress understanding more of what I have been going through for the last 12 years. I appreciate the info re: the new laws and the RFA form. I had a letter typed up and other evidence, but no RFA forms ever mentioned by atty or pharmacist or med doc or PTP. I will get on that issue immediately. It is amazing that even when working for local government and all, I still am amazed at the level of bureaucracy involved, to the extent where people are not the issue and those into fraud and greed do not help, especially when one still wants to believe and reality keeps revealing it is not to be, have fun, love the life we have and be happy with what is truly important, stop sweating the small stuff and all will be what is. I will ask my atty when I see him about the past medical costs for the last 12 years and if he is willing to do the medical buy out, with my assistance. It was explained to me so well, I do not know if I would even attempt to do a buyout, just keep filling out forms and taking care of me with my docs and faith. Sincerely.
 
Reply
#17
This system is much too complicated in our state, and who suffers is the injured worker.

Once you know the basic rules, you should be able to find out why you are not receiving anything from UR. Either your doctor is not requesting it correctly, he is not in the MPN network, OR your adjuster is illegally ignoring his requests. You should get a copy of all UR approval and denials. It is illegal not to copy you, even if represented. With a UR denial they have to include a paper on how to request an IMR (independent medical review).


Again, the best way to track this is to ask someone in your doctors office for a copy of his last request RFA form and any fax or mail confirmation that shows when it was sent. What some patients have found is their doctor is just writing prescriptions without sending in an RFA. The adjuster can ignore those prescription requests from your pharmacy.

Chances are high your pharmacist has little to no knowledge of what an RFA form is. Most are not that familiar with the work comp laws. They really have no involvement in a work comp case, unlike your doctor. I did have to send my new doctors office a link to the RFA form as he was also making requests without the correct form, and they were ignored. Many doctors in the MPN's are not familiar with current work comp rules and regulations. Again, it is the patient who suffers.

I think requesting a in person or phone appointment with your attorney would be helpful. He should be getting copied on your doctors RFA requests. He should be able to look in your file and determine what the issue is and how to resolve it.

I know you mentioned a medical buyout is what you are interested in. I just wanted to reiterate these things in case that does not happen, and also just for your own knowledge if you want to track this issue.

I wish you the best of luck.
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.
 
Reply
#18
I finished my morning prayer giving thanks for you that have helped me understand in so many ways, there were simple dots that were missing, breaking the connections of why. Now this morn you have validated what 2 things I did yesterday. I called my Pain mgmt. Dr. they have not been using the RFA form for the prescription and will start at next visit, thank you, as that explains why we received no response from UR except on the one drug whose responsibility is based at 56%, willing to let go but not the highly addictive, life-altering patches I am wearing for 12 years. My PTP wc comp, who has always taken care of me, in more ways than I can believe at times when I in need, are up tp date on all RFA forms and appealing for less invasive treatment that has been assistive for me with a 50% reduction in the meds to regain my cognitive abilities. To go from a highly commended investigator to what my abilities are today is hard for people to deal with as I get confused, especially in the beginning when I "hijacked" a conversation and received immediate assistance to start my own "thread", thank you all for your validation, information, compassion, knowledge and wisdom. I want to have what works for me so I can live peacefully for the short time we are given on this beautiful earth. With my pharmacist, I appreciate your clarification of their part as they have been with me for appx 30 years and do what they can as well which is where I got my copies of their refusals of payment, etc., I am still stuck on how to obtain 12 years, other than to estimate thru my records, then have PTP's feedback. Would I include the procedures my PPO covered in lieu of wc denials or allow the 2 to go at it when WC has more percentage responsibility than PPO or just keep on doing, PTP will not abandon as he has witnessed my desire to live and wrote my final with an 86% pd rating. Due to a 1987 DOI, I had a 45% pd on left knee as a lower position, this was why my atty said he advised the 56% acceptance = $66K. We are going to court Monday for an underpayment on my side which bothsides verified with judge and WC refuses to provide accounting, atty said I will receive interest on the amount since the award of 1/6/14. Will see how the future moves and now that I am more educated and the dots connect, I will have another conversation with atty and email him now, he is very kind and I am not easy to understand these days so I cry, it sucks, but that's me. Have a blessed day.
 
Reply
#19
Sweet sahaha, I am very sorry for what you and many, many other injured workers in this state are going through. It is absolutely disgusting to me that injured workers are not being provided with proper medical treatment.

In regards to your situation with private insurance, you should confirm with your attorney but it is my understanding you can use private insurance if you are being denied medical treatment through work comp. I know of many who are not only using their private insurance for their medications, but also for MRI's physical therapy etc. Again, this is something you should discuss with your attorney.

Have you kept your receipts for your out of pocket expense of co-pays etc? You may be able to get a print out from your pharmacy. You can tape the receipts onto typing paper and number the receipts, and print out a mileage form from the states website and white out the mileage section at the top and use it to list the out of pocket receipts and amount spent. I would ask your attorney but many turn in receipts like this. If you have copies of your doctors requests from years ago, that were ignored for this medication, this may be grounds to get some of that reimbursed. The new laws went into effect July 2013 for your date of injury, to use RFA forms.

I am glad you were able to track down the problem. Since your doctor was not using RFA's this tells me he may not be well versed with CA work comp new laws. If he does not include medical reasoning with his RFA forms, chances are high you may get a denial. There are two appeals processes available, and they both have strict deadlines. You or your doctor can appeal the UR denial usually through the appeal process with the UR company. If that gets denied you, your doctor or attorney can request an IMR. With medications it is best that the doctor is appealing this as it is very complex, but I have had some success appealing this without a doctor, I just do not recommend it. If you need help with this appeal process or anything else please let me know. I am not an expert, I have just been dealing with this as an injured worker.

This system is very stressful and I know even more difficult to deal with while in pain and on pain medications. Please know you are not alone. I am very relieved you have private insurance that is covering your medications through this.

I do want to ask if you are currently working and if not I would recommend you apply for SSDI. SSDI (social security disability) can be awarded or those who cannot work for a 12 month period due to a disability. You did mention you worked for the state, and in that case you may not qualify (unknown).
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.
 
Reply
#20
Good Afternoon, I was reading back through everything and am going to research the links provided. I agree with eliminating fraud and as an investigator, aware there is fraud in all programs, some people may look at as a vacation with a reward, I would much rather be living off my paycheck, I understand cutbacks,but not cold denial and an examiner I will be filing a complaint against for a few documented reasons, she was told by my atty to not call me again and she got worse with doc staff and denial of highly documented needed assistance. When there are significant serious injuries of 12 years and the new insurance company which took over about 9 months ago when the denials flooded, they may or may not have the historical bills they paid in 1 or all 4 cases in their files or if the old company that is gone now kept everything and my wc medical payment history amount is not available, can I estimate what has been paid, with my PTP and atty help? I am not able to work and not Social Security eligible, as my county retirement plan has a LTD benefit which is governed by the social security qualification regulations for total permanent disability, which I have due to work injuries and personal medical issues, with WC having a greater percentage of disability, I am blessed with employer provided insurance, not medicare eligible until 10/18, not social security eligible, when I retire I will have my retirement only. The local government I work for took us out of social security in '83 when it privatized and did a number on our retirement plans, young and believing in my government and what they said was good for my career and future I lost a lot. I'm blessed tho. Yes my atty said I'm fine with using my insurance when it becomes a battle, I have eliminated a number of the battles with them to keep my wits about me, however, I lost money but I have me, I am not into anymore debt than what life gives us already, have a roof over my head and caring people to touch many areas of my life. I feel a big gift of stress relief from understanding why, what, how more now. I do not understand how a law enacted in 2013 can affect a Judge signed stip/award of 1/6/14 with AME recommendations in the stipulation can bear no weight in my PTP's request for procedures, etc. as he has used the RFA forms for everything, the requests for copies from them is available is covered and they do the appeals for me, atty recently did 2, we do need to pick our battles and I am and have and will in a more effective way I hope. Knowing your assistance can help when the confusion is present is reassuring. I am used to my life being doc appts and all that goes with it and spend 90% of my life in my home. I worked the streets for years, highly commended, my brain is returning, I want to enjoy what's left of this short time we have here. I have been off work since 08 and went downhill and began the climb back up to a level of happy and hopeful. There is help when I asked, more offered if needed, you are here in this forum, this help feels like a first in a long time and will make my atty happier as he will understand I understand more now for the most part, at least basically and what I can do to help me, too. thank you, sincerely.
 
Reply
  


Possibly Related Threads...
Thread Author Replies Views Last Post
  And The Fight Begins.... NY tbear6410 41 3,244 09-07-2019, 08:07 PM
Last Post: California_Help
  Medical set-aside inquiries Andy1689 4 586 09-04-2019, 12:45 AM
Last Post: 1171
  settlement with open medical Andy1689 2 461 08-25-2019, 02:54 PM
Last Post: 1171
  Medical set aside redsoxfan 21 1,346 08-11-2019, 03:07 PM
Last Post: 1171
  Maximum Medical Improvement lovemygirls02 9 1,022 08-10-2019, 05:48 PM
Last Post: Turtle23
  open medical pros and cons freebird 23 33,304 07-08-2019, 09:27 PM
Last Post: Bets
  Leaving your medical open Bets 6 967 07-08-2019, 01:47 PM
Last Post: adkreb
  New claim in Massachusetts, do I sign Medical Authorization Release Form??? spoe.eops 3 364 05-30-2019, 09:21 PM
Last Post: 1171
  Workers Comp Disputing Medical Bills gamora77 1 681 03-15-2019, 11:22 PM
Last Post: 1171
  Lifetime medical payout Jerry_Rivera 2 612 03-12-2019, 11:04 AM
Last Post: 1171

Forum Jump:


Browsing: 1 Guest(s)