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Permanent & Stationary (P&S)
#11
Okay. I’m beginning to see the light. Not that it makes me feel any better but it helps to understand that WC can be a very complicated process. Thank “God” for Attorneys. I already have a disability rating which is on the low side (but WC also says I’m permanently disabled and will not release me to return to work) so I wonder about all the fanfare regarding my case. I had two QMEs. The first was outright rejected by my Attorney. The second one was accepted by all parties. In my particular case I can see the tit-for-tat going on witnessed by the foot-tall stack of copies of correspondence (and still growing) between the carrier and my Attorney, et al. My Attorney will cite/argue a specific rule(s) on my behalf and the carrier then shoots back that the rule is being misinterpreted or cites a contradicting rule, etc. So they end up going back and forth nonstop. It seems that the carrier bickers about every little detail. Of course all this “bickering” just creates more delays. I’m beginning to wonder if my case is rare or is this norm for everyone. Regarding my knee, the language used by the carrier is something like “the knee is not an accepted body part of this claim.” Then the letter goes on to say for me to call my Attorney if I disagree with the decision. I already have contacted my attorney and the carrier just consistently repeats the same statement every time my doctor requests treatment for my knee. My doctor agrees that the knee injury is a result of my limping etc. As regards surgery I too am not a proponent of surgery as I have heard horror stories etc. When I use the term “surgery” I’m assuming that’s how my hip labral tear will be repaired because no amount of physical therapy will repair the tear, only make it worse (I’m assuming again). And I also now see that surgery is not always an automatic consideration with WC. Apparently WC can also order physical therapy or whatever is out there or simply rule that the injured person is permanently disabled (in their eyes), do a settlement along with a WCMSA, and let the injured individual take care of the problem (as 1171 suggested). So if this is the case then it looks like I should not expect to be getting any kind of medical treatment from within the WC system until after the settlement/WCMSA is completed? In the meantime I know I have the option of seeking treatment elsewhere.

Actually the only reason that we are in the settlement/WCMSA process is because the carrier wanted to know if I would be “interested” in settling (I have already gone beyond the QME, MMI and P&S).

Here is an additional point: does taking pain pills or any other kinds of medications become part of the equation when it comes to determining P&S? I am not a proponent of being on pain pills for over four years but if not for the pain pills I would be a living slug (without the shell kind). Even now the carrier is attempting to reduce the number of pain pills I get every month (could this be due the carrier wanting to wind down my case?).

Again thanks to all who have given me a lot of new and challenging insights.
 
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#12
maintenance treatment often includes regular medications. " P&S" is a legal term for a medical opinion that excludes foreseeable "significant" changes in the medical condition.
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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#13
(12-29-2015, 04:23 PM)DISGUSTED TO THE T Wrote: Okay. I’m beginning to see the light. Not that it makes me feel any better but it helps to understand that WC can be a very complicated process. Thank “God” for Attorneys. I already have a disability rating which is on the low side (but WC also says I’m permanently disabled and will not release me to return to work) so I wonder about all the fanfare regarding my case. I had two QMEs. The first was outright rejected by my Attorney. The second one was accepted by all parties. In my particular case I can see the tit-for-tat going on witnessed by the foot-tall stack of copies of correspondence (and still growing) between the carrier and my Attorney, et al. My Attorney will cite/argue a specific rule(s) on my behalf and the carrier then shoots back that the rule is being misinterpreted or cites a contradicting rule, etc.  So they end up going back and forth nonstop. It seems that the carrier bickers about every little detail. Of course all this “bickering” just creates more delays. I’m beginning to wonder if my case is rare or is this norm for everyone. Regarding my knee, the language used by the carrier is something like “the knee is not an accepted body part of this claim.” Then the letter goes on to say for me to call my Attorney if I disagree with the decision. I already have contacted my attorney and the carrier just consistently repeats the same statement every time my doctor requests treatment for my knee. My doctor agrees that the knee injury is a result of my limping etc. As regards surgery I too am not a proponent of surgery as I have heard horror stories etc. When I use the term “surgery” I’m assuming that’s how my hip labral tear will be repaired because no amount of physical therapy will repair the tear, only make it worse (I’m assuming again). And I also now see that surgery is not always an automatic consideration with WC. Apparently WC can also order physical therapy or whatever is out there or simply rule that the injured person is permanently disabled (in their eyes), do a settlement along with a WCMSA, and let the injured individual take care of the problem (as 1171 suggested). So if this is the case then it looks like I should not expect to be getting any kind of medical treatment from within the WC system until after the settlement/WCMSA is completed? In the meantime I know I have the option of seeking treatment elsewhere.

Actually the only reason that we are in the settlement/WCMSA process is because the carrier wanted to know if I would be “interested” in settling (I have already gone beyond the QME, MMI and P&S).

Here is an additional point: does taking pain pills or any other kinds of medications become part of the equation when it comes to determining P&S? I am not a proponent of being on pain pills for over four years but if not for the pain pills I would be a living slug (without the shell kind). Even now the carrier is attempting to reduce the number of pain pills I get every month (could this be due the carrier wanting to wind down my case?).

Again thanks to all who have given me a lot of new and challenging insights.



The insurance carrier is denying your knee. The next step should be is your attorney should send you back to the QME to opine if the knee is a consequence of your injury. Until the QME opines on this, you will not be able to get treatment within the work comp system for your knee. I recommend asking your attorney what his plan is for this body part that is in dispute and is he going to send you back to the QME or ask the QME for a supplemental? This is the process for a denied injury. He can also take the issue to a hearing and let the judge decide. Usually going to a QME or AME is the course for denied injuries.


It is still unknown to me why you cannot get referrals for specialist ad also treatment for your injury. This is usually due to the treating doctor is not writing appropriate requests with medical reasoning and medical treatment guidelines, and/or is not appealing the UR denials. If this has been going on for a while, I would consider changing doctors. You can also change doctors to the specialty you need (ex ortho surgeon). I would not give up on surgery if it is found this can possibly repair your injury.


The Medicare set aside is for people who close out the medical portion of their claim for a lump sum. You are not forced to do this and it is up to you if you want to close out the medical in your claim. Judging by how you are not receiving much treatment, it may benefit you to close this out and use Medicare after the MSA is exhausted. What you are describing as far as not being able to receive treatment for accepted injuries is not the norm in this system, but happens enough. This should not be happening to you and why I wrote above your doctor is the gatekeeper to your medical treatment. Without a good gatekeeper, you will not receive proper medical treatment in this system. I recommend discussing this issue with your attorney. he should know how well written your doctors reports are, and if this is preventing you from receiving treatment. 


The amount of medicine you are taking has nothing to do with P&S. It does have something to do with a MSA. they are going to estimate/calculate how much this medication will cost over a lifetime. This is why some believe many carriers and now unilaterally denying injured workers medications as it makes the MSA higher when they are taking high amounts of medications. The MSA does not help you so much as it helps Medicare. I do not know why your carrier is trying to cut down your medications, but this is happening to many. This is cost containment in my opinion and without a doctor to appeal these denials, it is very difficult to prevail with IMR with a medication denial. Again, your doctor is the gatekeeper of your medications and without a gatekeeper who writes well written requests with medical treatment guidelines on why the medications are needed AND UR appeals it will be difficult to get medication denials overturned.
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.
 
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