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Calif UR doctors denying/Cashing out Medical. 1171
#11
(08-07-2017, 07:32 PM)Babebahn Wrote:
(08-06-2017, 06:49 PM)California_Help Wrote: So I asked this question to several applicant attorneys, if you can use Medicare after UR has denied medications.

First attorney responded yes, but the Medicare lien would have to be dealt with at the time of settlement. Another attorney stated just yes, and the third attorney stated an injured worker can step outside of the CA WC system and use private insurance or Medicare any time you want, even without a claim denial or UR/IMR denial and Medicare will place a lien. Again, I recommend calling Medicare and see what they tell you and go by that.
 I did contact Kaiser and Medicare. I do not have part D I only have Part A & B (hospital/medical) I asked about sending or Even bringing in my letters of denial to Medicare to see what they could do only to be told "I'm sorry we will not cover your medication prescribed by your pain management physician who is not part of Kaiser

Do you have both Kaiser (private insurance through employer or spouse) and Medicare (as secondary insurance), with Kaiser having prescription coverage? I was not aware when you wrote your post you did not have part D. I should not have assumed.
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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#12
(08-08-2017, 10:55 PM)MCalifornia_Help Wrote:
(08-07-2017, 07:32 PM)Babebahn Wrote:
(08-06-2017, 06:49 PM)California_Help Wrote: So I asked this question to several applicant attorneys, if you can use Medicare after UR has denied medications.

First attorney responded yes, but the Medicare lien would have to be dealt with at the time of settlement. Another attorney stated just yes, and the third attorney stated an injured worker can step outside of the CA WC system and use private insurance or Medicare any time you want, even without a claim denial or UR/IMR denial and Medicare will place a lien. Again, I recommend calling Medicare and see what they tell you and go by that.
 I did contact Kaiser and Medicare. I do not have part D I only have Part A & B (hospital/medical) I asked about sending or Even bringing in my letters of denial to Medicare to see what they could do only to be told "I'm sorry we will not cover your medication prescribed by your pain management physician who is not part of Kaiser

Do you have both Kaiser (private insurance through employer or spouse) and Medicare (as secondary insurance), with Kaiser having prescription coverage? I was not aware when you wrote your post you did not have part D. I should not have assumed.
I only have prescription coverage with Kaiser. Medicare is my secondary.  No I do not have Part D Medicare coverage.
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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#13
(08-12-2017, 03:03 AM)Babebahn Wrote:
(08-08-2017, 10:55 PM)MCalifornia_Help Wrote:
(08-07-2017, 07:32 PM)Babebahn Wrote:
(08-06-2017, 06:49 PM)California_Help Wrote: So I asked this question to several applicant attorneys, if you can use Medicare after UR has denied medications.

First attorney responded yes, but the Medicare lien would have to be dealt with at the time of settlement. Another attorney stated just yes, and the third attorney stated an injured worker can step outside of the CA WC system and use private insurance or Medicare any time you want, even without a claim denial or UR/IMR denial and Medicare will place a lien. Again, I recommend calling Medicare and see what they tell you and go by that.
 I did contact Kaiser and Medicare. I do not have part D I only have Part A & B (hospital/medical) I asked about sending or Even bringing in my letters of denial to Medicare to see what they could do only to be told "I'm sorry we will not cover your medication prescribed by your pain management physician who is not part of Kaiser

Do you have both Kaiser (private insurance through employer or spouse) and Medicare (as secondary insurance), with Kaiser having prescription coverage? I was not aware when you wrote your post you did not have part D. I should not have assumed.
I only have prescription coverage with Kaiser. Medicare is my secondary.  No I do not have Part D Medicare coverage.
OK, now I clearer picture of your situation. Medicare will not cover this. When you state you only have prescription coverage with Kaiser, I assume you also have medical coverage to see a Kaiser doctor?

Can you go to a pain management doctor or even a general practitioner under Kaiser and tell them your situation, you were cut off and denied your medications through a paper UR review? Kaiser told you only a Kaiser doctors prescription will be covered. I am not familiar with Kaiser, only that other CA IW's have stated they were not treated very well and had difficulties getting treatment. Another idea would be to call Kaiser and ask their policy regarding denied treatment by work comp and ask for a copy of their policy. Some private health insurance companies also have nurses you can call when you need assistance.

If Kaiser refuses then you can try contacting this organization to see if you have rights under your private health insurer to cover these prescriptions. I have no idea if they do.
http://www.healthhelp.ca.gov/
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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#14
(08-04-2017, 05:32 PM)Babebahn Wrote:
(08-04-2017, 11:12 AM)1171 Wrote: On large buyouts-$250k- Medicare pre-approves the treatment settlement amount.
If the carrier is still willing to settle then once the court approves the money goes to a third party administrator or to you to self -administer. I posted links to the CMS and set aside web sites in other recent posts. (Loki & bobcat)
All carriers are required to alert CMS of any comp claims to Medicare eligible workers.
This doesn,t apply to private insurers.
Thanks 1171,  I did find those posts on this Forum. Stayed up until 3:30 am researching. I'm just trying to figure out if this is the right thing to do!
*UPDATE*
After all the stress waiting for some sort acknowledgement from Medicare/CMS I received their "quote" for my future medical allowance... it was over $500,000.  Work Comp recently sent a letter stating they would not approve this figure and will continue to pay for my medical.  All of a sudden they are paying for my medication and procedures.  I guess they figured it was cheapest to pay for my medication and procedures rather than paying me over $500,000... so back on the band wagon we go.  I did finally get an appointment with my long lost attorney who did state that once a claim is settled, he no longer has to assist in any matters.  I reminded him that at no time during the settlement did he ever tell me that UR would determine if they would pay or not, I also told him that at no time did her EVER tell me that I could re-open my case up to 5 years after settlement, and at no time did he tell me that if with all the complications that I had from the day of surgery to present that I could have opened a new case... the long and short of it is  What I know now, I would NEVER EVER have settled my case!  Lesson Learned
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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#15
He is incorrect about his post-award duty to you. Only the WCAB can relieve him his atty - client relationship.
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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#16
P.s. You may want to notify him in writing that if there is a settlement of your remaining medical benefits you Will Object to any additional fee for him since he decided to remove himself from your representation without your knowledge.
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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