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1171-Utilization Review Denial/Atty not actively representing
#1
Hi 1171,
I just received a letter from my attorney stating "utilitization review denial/modification". What shocked me about this letter was the following: Recently we receive a letter dated 3/15/16 indicating w/c adjuster has denied medial branch block recommended for your injury by your treating physician pursuant to so called utilization review.  We have closed your file and are not actively representing you (?) huh? I do not have all of the relevant medical reports and other documents, however we recommend that you take all the the following actions Asap: object to the denial, sign application for independent medical review  and immediately make an appointment with your physician regarding this matter. By this letter, we are not agreeing to represent you at this time.  We are not taking any action on your behalf.  Our conclusions are preliminary and tentative because we do not have all of the medical reports (they have been receiving all progress updates/test results) and other documents necessary to fully analyse.  You are of course free to contact other attorneys of your choice to proceed on your own, but be aware time is of the essence."  I immediately called my attorneys office and spoke to his assistant, I read her this letter and I said: "when did Mr Attorney release me as his client?"  She stated that he didn't but I told her that's not what the letter says. I tried to no avail to tell Her, the letter does not imply that this is only regarding this utilization matter, but implies that Mr. Attorney is no longer my attorney. She kept saying I was wrong, so I finally told her, maybe I'm not making myself clear and need to contact Mr Atty to clarify this.  
My question to you is I thought I had an attorney with a lifetime medical still open, what the hell do I do from this point? I immediately scheduled an appointment with my doctor to work on the denial. H E L P
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
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#2
the first thing is to notify the attys office that you are sending a copy of their letter to the state bar with a complaint.
your atty got paid to represent you on your entire case for as long as it lasts. that's why the carrier sent them updated medical and the UR denial.
include in your notice to the atty a request that they return the fee that was paid to them--they can't have it both ways.
this atty took your fee and no atty will step in now to help you-- as they won't get paid.
the atty was right to advise you to take over the IMR appeal process.

here is link to atty complaint process
http://www.calbar.ca.gov/Attorneys/Lawye...ation.aspx
here is information on the IMR process
http://www.dir.ca.gov/dwc/IMR.htm
the only way you might possibly get another atty to step in now is if you were willing to do a C&R--that's the only way another atty fee could be paid. there are no guarantees a C&R would get done so it's a longshot.
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
I know this was addressed to 1171, but I wanted to let you know you/your doctor has 10 days from the date of the UR denial to send in a internal utilization appeal. There are directions on the last few pages of the UR denial where to send it. You also have 30 days to send in an IMR to MAXIMUS. I HIGHLY recommend blacking out your attorney's name and contact info on the IMR form because he will receive notification when you can send records and not you. So there are two possible appeals for UR denials...internal 10 day UR appeal and IMR.

 First thing I recommend is to look at the UR denial date and see if you are past the 10 day mark and if so move on and request an IMR. The IMR form and UR denial should have been sent to you together. If you write the reasons for the UR denial I can try to help you write an appeal (if your doctor will not do it).

I do wonder if this letter from your attorney was a typo or mistake. I would recommend asking for a phone appointment with him to discus and ask him to send you a letter stating he is still representing you (if he is). Many work comp attorney's do not help with these denials or they only send in the IMR form. You really need to send in an appeal letter that addresses the reasons for the denial with relevant records and treatment guidelines. Those with lifetime medical are subject to UR and IMR process just like all CA IW's. I recommend doing aggressive appeals to ensure you get proper treatment.
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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#4
(03-18-2016, 01:17 AM)1171 Wrote: HI 1171...
As I'm writing you this note, I'm also in the process of writing my attorney a letter as well! At the time of settlement, my attorney was paid this rightful amount plus I gave him an additional $10,000 for retainer fees in case anything came up... well something has come up!
I did see my doctor immediately on friday and they started the ball rounding on the appeal.  I even had my cousin who is a Senior Paralegal to read the letter yesterday, and she even said the letter was implying "your attorney is no longer representing you"
Thank you so much for your help... I'm breathing a little bit easier now...



the first thing is to notify the attys office that you are sending a copy of their letter to the state bar with a complaint.
your atty got paid to represent you on your entire case for as long as it lasts. that's why the carrier sent them updated medical and the UR denial.
include in your notice to the atty a request that they return the fee that was paid to them--they can't have it both ways.
this atty took your fee and no atty will step in now to help you-- as they won't get paid.
the atty was right to advise you to take over the IMR appeal process.

here is link to atty complaint process
http://www.calbar.ca.gov/Attorneys/Lawye...ation.aspx
here is information on the IMR process
http://www.dir.ca.gov/dwc/IMR.htm
the only way you might possibly get another atty to step in now is if you were willing to do a C&R--that's the only way another atty fee could be paid. there are no guarantees a C&R would get done so it's a longshot.
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
Reply
#5
(03-18-2016, 12:50 PM)California_Help Wrote: I know this was addressed to 1171, but I wanted to let you know you/your doctor has 10 days from the date of the UR denial to send in a internal utilization appeal. There are directions on the last few pages of the UR denial where to send it. You also have 30 days to send in an IMR to MAXIMUS. I HIGHLY recommend blacking out your attorney's name and contact info on the IMR form because he will receive notification when you can send records and not you. So there are two possible appeals prices for UR denials, internal 10 day UR appeal and IMR.

 First thing I recommend is to look at the UR denial date and see if you are past the 10 day mark and if so move on and request an IMR. The IMR form and UR denial should have been sent to you together. If you write the reasons for the UR denial I can try to help you write an appeal (if your doctor will not do it).

I do wonder if this letter from your attorney was a typo or mistake. I would recommend asking for a phone appointment with him to discus and ask him to send you a letter stating he is still representing you (if he is). Many work comp attorney's do not help with these denials or they only send in the IMR form. You really need to send in an appeal letter that addresses the reasons for the denial with relevant records and treatment guidelines. Those with lifetime medical are subject to UR and IMR process just like all CA IW's. I recommend doing aggressive appeals to ensure you get proper treatment.


Thanks California Help...I did call my attorney's office and ask for an appointment and was denied! I also saw my doctor on friday to get the Appeal process going.  I'm writing a detailed letter to my attorney asking for justification for the letter I received.  Thank you for comments, I appreciate it. Smile
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
Reply
#6
(03-21-2016, 03:46 PM)Babebahn Wrote:
(03-18-2016, 12:50 PM)California_Help Wrote: I know this was addressed to 1171, but I wanted to let you know you/your doctor has 10 days from the date of the UR denial to send in a internal utilization appeal. There are directions on the last few pages of the UR denial where to send it. You also have 30 days to send in an IMR to MAXIMUS. I HIGHLY recommend blacking out your attorney's name and contact info on the IMR form because he will receive notification when you can send records and not you. So there are two possible appeals prices for UR denials, internal 10 day UR appeal and IMR.

 First thing I recommend is to look at the UR denial date and see if you are past the 10 day mark and if so move on and request an IMR. The IMR form and UR denial should have been sent to you together. If you write the reasons for the UR denial I can try to help you write an appeal (if your doctor will not do it).

I do wonder if this letter from your attorney was a typo or mistake. I would recommend asking for a phone appointment with him to discus and ask him to send you a letter stating he is still representing you (if he is). Many work comp attorney's do not help with these denials or they only send in the IMR form. You really need to send in an appeal letter that addresses the reasons for the denial with relevant records and treatment guidelines. Those with lifetime medical are subject to UR and IMR process just like all CA IW's. I recommend doing aggressive appeals to ensure you get proper treatment.


Thanks California Help...I did call my attorney's office and ask for an appointment and was denied! I also saw my doctor on friday to get the Appeal process going.  I'm writing a detailed letter to my attorney asking for justification for the letter I received.  Thank you for comments, I appreciate it. Smile
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
#7
(03-21-2016, 03:46 PM)Babebahn Wrote:
(03-18-2016, 12:50 PM)California_Help Wrote: Thanks California Help...I did call my attorney's office and ask for an appointment and was denied! I also saw my doctor on friday to get the Appeal process going.  I'm writing a detailed letter to my attorney asking for justification for the letter I received.  Thank you for comments, I appreciate it. Smile
What was the reason they gave that you cannot have an appointment with your attorney? This does not sound right to me. I recommend googling this attorney and write reviews under to see if he has a pattern of abandoning his clients.

Your doctors office can also attempt a peer to per call again under the UR appeals process on top of sending in a written appeal.

Please let me know how the UR appeal goes, and I recommend sending in the form for an IMR, just so you do not go past the deadline. (Make sure you black out your attorney's info). If you get this approved through UR appeal you can always call MAXIMUS and cancel the IMR.
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
#8
Hi 1171! Here's my update:  Attorney wrote back, still referring to "2004, Gov. Schwarzeneger pushed through Senate Bill 899 which radically cut injured workers rights. And Gov Brown's Senate Bill 863: to take the ability to litigate medical treatment disputes away from the courts and transfer it to a secretive private for profit corporation such as Maximus Inc.
I found my reward letter and the break down of fees awarded to my attorney and it shows he was paid the amount from work and he added $10,00 more that we discussed in the hallway of W/C... however it doesn't show  $32,000 plus additional $10,000. this was agreed upon in the hallway with my adult son present. No written documentation!  Now I really feel stupid!
I spoke to work comp today and told her my atty is not presenting me for the Utilization Review Denial.  She stated "HE HAS TO PRESENT YOU, he hasn't sent a letter telling you or W/C that he has relinquished his services. He was paid to be your attorney of recorded and we paid him so."
My doctors office has dropped the ball in regards to the "denial letter,  I have another appt w/ my doctor to remedy this whole mess.  Appparently, they have called my doctor 3 times and no one has called back!
Right now, I feel very lost and alone with this whole thing with my attorney.  I know I'm backed into a corner because no "new atty" will help at this point.  I have sent off IMR and also sent a copy to my claims administrator,...
So should I contact the Dept of Workers Compensation in Oakland and tell them what is going on OR just leave it alone...

Feeling totally lost
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
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#9
you can call them but they have no legal authority over atty performance and, of course, neither does your adjuster.
I don't know anything about your settlement amounts so can't really comment.
the correct process for complaints about atty performance is the state bar.
you can change doctors within the MPN at any time. make sure you get one that will appeal denials.

it's possible you health insurer will provide coverage for treatments denied by comp.
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
#10
(03-22-2016, 07:50 PM)California_Help Wrote:
(03-21-2016, 03:46 PM)Babebahn Wrote:
(03-18-2016, 12:50 PM)California_Help Wrote: Thanks California Help...I did call my attorney's office and ask for an appointment and was denied! I also saw my doctor on friday to get the Appeal process going.  I'm writing a detailed letter to my attorney asking for justification for the letter I received.  Thank you for comments, I appreciate it. Smile
What was the reason they gave that you cannot have an appointment with your attorney? This does not sound right to me. I recommend googling this attorney and write reviews under to see if he has a pattern of abandoning his clients.

Your doctors office can also attempt a peer to per call again under the UR appeals process on top of sending in a written appeal.

Please let me know how the UR appeal goes, and I recommend sending in the form for an IMR, just so you do not go past the deadline. (Make sure you black out your attorney's info). If you get this approved through UR appeal you can always call MAXIMUS and cancel the IMR.

Saw my physician this past friday... or should I say I saw the "fellowship nurse practitioner" I explained that the Perr Review Physician has left 5 messages for the authorization department, I have left 3 messages with the authorization the department and no one has called back... the NP said my Doctor is a very busy man and doesn't have the time... but you might consider having a stimulator placed into your back and neck SMH... As I was leaving I saw my doctor, made eye contact and said "I'm very disappointment with the way your authorizaton dept and you have handled this whole thing, it would have only taken for you or your authorization dept to return a call and also send the correct documentation needed"  He told me "Have a great weekend"
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
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