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medical release/buyout? and/ or fight for medical ongoing

Many injured workers are suffering due to the law that was passed, SB863. Insurance companies are now using the UR and IMR system to deny medications, especially in older claims who have a lot of expensive medications. Many injured workers feel as you do about their past AME determinations and what their open medical stip entailed, as now all requests are subject to UR/IMR.

The DWC made a written statement a few weeks ago that insurance companies should not be using the UR and IMR system to unilaterally deny medications, and that there should be a change of condition before medications are sent through UR. I do not believe this will stop the insurance companies from doing this, until this is made into a rule they must follow.

If you are considering a compromise and release, the things I would recommend looking into is will your PPO treat your injuries and medications or will you have to pay out of pocket. I am not sure I understood your comments about your LTD policy. Did you qualify and are you receiving LTD? If you are I would also recommend requesting a complete copy of your LTD policy if you are considering a C&R. I have read on a few forums that some LTD companies count work comp compromise and release money as income and will offset their payments. This means they stopped paying the claimant and spread out the award asit was income. Since you have a state LTD, and every LTD policy is different, I suggest reading your policy to check this. I do not want to worry you. I just wanted to mention just in case you have that language in your LTD policy. You may already know this as they would most likely have offset your work comp payments in the past. You can also have an ERISA attorney review your LTD policy to be sure.

I would not be concearned with having to locate documentation as to how much the work comp carrier has spent on your injuries (JMO). Your attorney should be well versed on C&R settlements and know the extent of your injuries.

Your claims adjuster should not contact you as you are represented by an attorney. You should not contact her either, unless your attorney has allowed this. If she calls you again, I would tell her you are represented and end the call.

You mentioned you were an investigator. California and actually all states have a very low number of injured workers who have been found to commit workers compensation fraud. In California it is something like 1/3 of 1% from what I have read. Medical provider fraud, insurance company fraud and employer fraud actually accounts for most of the fraud in workers compensation. I believe most would prefer to live off of a paycheck and not be in this horrid system. Unfortunately in California, it is employers who provide the monies to the agency who investigates this and why many believe insurance companies and employers are not being investigated as much as they should, since they are commiting most of the fraud. All fraud is bad for everyone no matter who commits it.

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.
I'm new to this forum so please forgive any mistakes regarding this issue or questions I may have. I am getting ready to settle a calif msa for $87k. I was under the impression I would be funded that amount and attend to this myself but I received a letter stating that I will get approx. $7k and the rest will be in $4,500 yearly increments yearly. Question: can I request 1/2 of the award in my account?
you need to start your own thread.
many visitors are looking for information from specific topics and introducing new questions can be confusing.
sounds like structured MSA. the terms of the settlement including how/when the MSA will be funded can be negotiated between the carrier and the worker.
the settlement amount for the MSA account requires pre-approval of CMS.
using MSA funds inappropriatelly will result in exclusion of medicare coverage for work injury treatment for the excluded amounts.
you should review the the WCMSA reference guide for basic information
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.
thank you. I'm not sure how to start my own thread but I appreciate your quick response and help to get my answers. But if I may just say that I have been at that page and although it has all the details , I wasn't able to find my actual question of if I can negotiate the initial "seed" money or have to accept the amount given. I have not signed and returned the papers yet. May I ask one more question please though? This is: in your opinion, is asking for approx. $30k asking too much or raising red flags or is this reasonable?
upper right-top of the page in the worker forum

yes you can negotiate with CMS for their approval amount.

there is no set amount for all injuries and all future medical needs.
have you reviewed the process that CMS uses to determine what is reasonable?

if you are going to negotiate with CMS, you will need to show that your figures for your future needs are more reasonable, accurate, and probable then theirs.

P.S. if you negotiate a lower future medical amount with CMS don't be surprised if the carrier reduces their settlement offer a corresponding amount. they are not llkely to allow 2 different future medical estimates with you pocketing the difference.
generally it's the carrier/employer that negotiates with CMS -- as its their $$$$.

if you read the reference guide, you should know that if the WCMSA amount is too high after a time you can have them reduce it.
in that case the reduction goes to you.
it may behoove the more sophisticated worker to allow a high initial amount funded from the carrier and try to get CMS to release some later. you'll have some usage history in a couple years which should make a lower recalculation easier.
if you see what I mean.

are you settling without an atty?
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.
thank you for replying. I am going to try to do this the correct way and start my thread. Hopefully, I will get another chance to get your advice. Ok, here goes!
Good Day, With my insurance, my out of pocket expenses, would be on me. The LTD is a 3rd party administrator for the county. I have been disabled, totally now for 7 years, worsening, yet battling hard to stay functional. When I was receiving WC TTD payments they processed my disability approved using Soc Sec regs and deducted TTD payments when stopped, they began the LTD payments. If the release is done it would be medical buyout only as the stip/award, although underpaid for which we are going to court for Monday, is a small amount, was signed 1/6/14. I received future medical. My LTD policy does not specify in my policy about a medical release buyout, Medicare does not apply due to the 30 month effective date not being applicable as my eligibleeffective date is 10/1/18 and the DOI 5/23/04, the stip/award1/6/14. If there were to be a medical buyout and there is no Medicare issue I would need to ask an ERISA atty about any money I may receive if they did a medical release as it may be deductible ajthough not handled in the court but between the 2 sides? I am glad to hear the info about history of paid medical costs, I can estimate with the numerous procedures I have had with my atty and docs if he agrees we go for it. WC fraud info you shared is appreciated as it reminded me of where the most fraud does occur, I have been treated terribly as well as other IW's I know and have heard about, we certainly are the smaller amount of the %. Yes, fraud is bad and we found more administrative errors in the fraud we investigated than those we prosecuted. My medical condition actually worsened and as I was losing my cognitive abilities and other issues from long time med needs. I requested to ween down and attempt to regain cognitive ability which has been somewhat successful for present time brain function, but long-time memory issues, confusion and dizziness remain I have been able to balance pain mgmt. with the meds, acupuncture, aquatherapy and other procedures with my ortho, such as injections, soft tissue therapy, however, my physical condition orthopedically is worsening, I do accept that there is a possibility of surgery in the future, for now I am homebound for the most part and am not desiring having any more surgical procedures in the near future, as much as a part of me wants to believe it may help, this time, I do not truly believe it. I have worked hard at not doing it. The low estimate from the spine surgeon for another "fix" is appx $200K for him alone, written in 2008 and left for open in my WC records due to increasing degeneration and many other things. I want to live not always be recovering from traumatic surgeries, for possible help, as I choose to stay in recovery mode after all that has already happened is a lot of work in itself. I do not want any more unless it gets to the point I am completely unable to walk. The claims adjuster stopped calling me and speaking her inappropriate feelings about my condition and personal matters for which she has not been trained as a medical doctor to input after contacted by my atty. She had her assistant put her name to it, who told me I could go off my addictive drugs cold turkey as I wanted a reduction. My pain mgmt. M.D. addressed her by name in his report and the atty did stop her from calling, now she denies every requested procedures though my name is on the denials as receiving a copy. My PTP's WC specialist keeps me well informed as to all the denials and their documented refusal to return the peer to peer calls, ex.: when 1 message had been left by the UR doc for a peer to peer this last month, my PTP attempted 6 call backs to the Dt., all documented, the new WC ins co. handling my case appears (to me personally) to make sure I am approved for nothing, so we appeal on and will when it is important, when it is a need and we have been denied/ignored or ? we use my priv ins. as my medical needs must be met and an award is not insurance. My out-if-pocket is $5-20k a year, not counting what is not covered by the ins, like the acupuncture. Is a medical buyout on future medical a C & R when the stip/award is technically already done, we are disputing their accounting in court and a medical buyout is out of court?
oh man, that is terrible. I feel fortunate now sahshah. The MSA is exactly for any future medications, surgerys, etc for the right hand. I will be able to purchase my meds on my own w/o having to get authorization which is going to be wonderful, but I want the full amount or at least most of it to use when I want and need something for the hand. I am fully aware of the reprecussions for not using the funds as intended, having to send a letter of expenses each year, etc, otherwise, why have to wait each year for more funds to be deposited?
Are there special circumstances or laws that have changed this and is it available if you are a settled case? Goes it affect any other benefits? I have a perm dis on 1 body part that was rated at 46% for my left knee in 10/89. In 1/14 I was rated a 56% pd on 10 body parts. I was told the 46% pd affected what % I was given during negotiations, PTP said 86%, AME gave no % and I was supposed to go to a rating. That's when we settled stip/award (although they have underpaid me and it will be heard mon). As my left knee is covered under both injuries, ratings, does that affect anything how do the 2 interact in negotiations and would the job position at the time of each injury being different have mattered and/or affected the rating? Is it a subsequent as the knee was rated at both settlements? In 1989 the adjuster took care of everything and truly treated me well, although they may not have paid a large amount, I received care, treatment, compensation for everything, respect and went back to work, although I received future medical in 1989 they refused to honor it at a later date, I was working and used my priv ins. In 5-04 when I was injured again (this stip/award) I did not get my loss of work time and pay returned, it was all included in the settlement amount, a few dollars over my yearly salary and they do not want to provide anything any longer. Is this fund possible for assistance. Do I have Sub Injury trust eligibility, I was wondering about this when I saw itand admit I have not fully researched it yet. Thank you.
To ellen122, thank you, you are fortunate. I do not know what a MSA is, maybe medical spending account, I assume. You are fortunate in more ways. Have a good day.

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