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PQME asked for another test. I live out of state.
#1
Insurance company had to pay and fly me to the state of my accident for my QME. Now per the QME, that doctor is asking for another test to be done. How can I do this when I live in Alaska and my QME was done in California? Who pays for this? I have checked with my current health insurance in Alaska and they will not take Calif Worker's Comp. Help!
 
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#2
it generally means they won't accept a reduced fee.
its up to the carrier to arrange for the test and complete the QME process.
you might have to pay for it out of pocket and get reimbursed. its however you and carrier agree to resolve 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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#3
(07-14-2015, 08:11 PM)1171 Wrote: it generally means they won't accept a reduced fee.
its up to the carrier to arrange for the test and complete the QME process.
you might have to pay for it out of pocket and get reimbursed. its however you and carrier agree to resolve it.

Carrier meaning my personal medical insurance? Then who reinburses me? Does my personal medical insurance (in Alaska) have to uphold an out of state(Calif) worker's comp case?
 
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#4
(07-14-2015, 08:25 PM)maizyrose Wrote:
(07-14-2015, 08:11 PM)1171 Wrote: it generally means they won't accept a reduced fee.
its up to the carrier to arrange for the test and complete the QME process.
you might have to pay for it out of pocket and get reimbursed. its however you and carrier agree to resolve it.

Carrier meaning my personal medical insurance? Then who reinburses me? Does my personal medical insurance (in Alaska) have to uphold an out of state(Calif) worker's comp case?
Or the carrier of the company in which my accident happened
 
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#5
most work comp claims are handled by a work comp insurance carrier unless the employer was self-insured or state entity. so the QME process should be handled by the employers workers comp carrier if they were insured.
your health insurer should not be involved unless comp benefits have been denied.
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
(07-14-2015, 08:40 PM)1171 Wrote: most work comp claims are handled by a work comp insurance carrier unless the employer was self-insured or state entity. so the QME process should be handled by the employers workers comp carrier if they were insured.
your health insurer should not be involved unless comp benefits have been denied.

Thank you. The employer was not self insured as they are national/international. The insurance asked me to go through my private medical insurance and find a Dr. to perform the test. During the time of my QME the employer also changed insururers so it has been almost a year since my QME of trying to get someone from the insurance company to respond and help. Comp benifits have not been denied. So frustrating and I thank you for your input. They wanted me to pay out of pocket for this test as well. I do not have the money to do this. Now I know they are legally bound to finish this process.
 
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#7
(07-14-2015, 11:52 PM)maizyrose Wrote: sounds like they are self-insured as claims are not passed from one carrier to another; they stay with the carrier that collected the premium.

if you are receiving all your benefits, then the onus to keep the claim open and unresolved is on them. if you have nothing to gain, I wouldn't worry about finishing the QME; its their problem.
you can always talk to an I&A officer for more information on navigating the california process.
probably the SF office would best handle your out of state contact
http://www.dir.ca.gov/dwc/IandA.html
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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#8
Yes, I did look back at the paperwork and my past workplace was self insured by Gallagher Bassett Services. Since my QME in California last Aug, Gallagher Bassett no longer is the administrator and I did not find out it was switched to a new administrator (Sedgwick) until late last year. My QME report took well over 90 days to receive.
I no longer receive benefits as I am permanent & stationary. Gallagher Bassett did not agree with my last Orthopedic doctor's report that did state I was permanent & stationary but I still had significant problems with strength due to pain and enough time had passed since my operations that the pain was going to be permanent. This physician wrote a paragraph on the future of medical care that I may need. Due to this report, Gallagher & Bassett requested a QME. My concern is for my future. I want to make sure if I need medical care for my disabilities (again, which that physician wrote in his opinion 100% of my present disability was caused by the industrial injury) I can get that and it is paid for or I receive a settlement. I am in a new job in Alaska with restrictions set by that Orthopedic Surgeon. I have put a call into the Oakland CA Worker's Comp Office.
I am angry that Gallagher & Bassett along with Sedgwick has dropped the ball. The fact this has almost been a year since the QME in CA and I am still getting incorrect info from Sedgwick as well as non communication. I cannot pay for this additional test out of pocket as it’s very expensive and I can’t believe they have asked me to go through my private medical insurance and find a doctor on my own. I just want to move forward with the assurance that I am either compensated or I can receive medical assistance from my injury.
 
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#9
(07-15-2015, 01:37 PM)maizyrose Wrote: only temporary disability benefits are stopped by being Permanent & Stationary. if there is permanent impairment then you are still owed disability for that as well as future medical treatment.

you should file a complaint with the audit bureau for their delay in determining/paying your PD benefits here:
http://www.dir.ca.gov/dwc/DWC_FilingAComplaint.htm

if treatment has been delayed, you can litigate with the comp court for a penalty. your I&A contact will have more information.
sounds like you might need an atty to take the matter to court. the administrator can stall and delay for a long time if you can't/won't get a judge 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.
 
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