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Prescriptions
#11
sometimes private insurance or medicare are not informed that workers comp denied the care/treatment. contact them again with proof of the denial maybe they will reconsider.
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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#12
(03-21-2018, 07:08 AM)tbear6410 Wrote: When I was scheduled for my SCS, that surgeon had me get the antibiotic before the surgery..

Calif....  here in NYS, if anything is Workers Comp, no other insurance will touch it.  Believe me... I had my own and if Comp refused to pay for it, my private ins. did too...   When I lost mine and was put on hubby's.. his did the same.  Just like Medicare and my supplementary insurance...  They won't pay for a comp thing.  I had a fight with them over appointments for my upper neck that is NOT comp...

I have a calif work comp case and my attorney keeps pushing me to take the settlement vs future medical( he wants to rid his hands of me) and he even has told me not to tell my private insurance that it was work comp related. He goes between forgetting he says that and "of course they will accept it, they can't not accept it" Answer to my case is this: WC denies, BCBS denies= I get no care and stay in pain. Sorry, didn't mean to but in
 
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#13
(03-22-2018, 04:30 AM)kibby Wrote:
(03-21-2018, 07:08 AM)tbear6410 Wrote: When I was scheduled for my SCS, that surgeon had me get the antibiotic before the surgery..

Calif....  here in NYS, if anything is Workers Comp, no other insurance will touch it.  Believe me... I had my own and if Comp refused to pay for it, my private ins. did too...   When I lost mine and was put on hubby's.. his did the same.  Just like Medicare and my supplementary insurance...  They won't pay for a comp thing.  I had a fight with them over appointments for my upper neck that is NOT comp...

I have a calif work comp case and my attorney keeps pushing me to take the settlement vs future medical( he wants to rid his hands of me) and he even has told me not to tell my private insurance that it was work comp related. He goes between forgetting he says that and "of course they will accept it, they can't not accept it" Answer to my case is this: WC denies, BCBS denies= I get no care and stay in pain. Sorry, didn't mean to but in

You can call your private insurance and ask if they cover injuries from a CLOSED work comp case and see what they say.
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
Just had a MRI denied through UR and IMR ..called medicare yesterday. Spoke to a benefits coordinator about Medicare acting as secondary coverage.

The answer is No! I got nowhere fast after an 81 minute wait time . They cited a US federal code. Said the treatment request was from a work comp provider , reviewed by a work comp ur doctor, and imr doctor . Said my remedy is the WCAB. Talk to your lawyer. Have a nice day.

They will not make any conditional payments .

I got a personal feeling that they have had absolutely enough of California's workers comp system.

My MPN doctor stepped up and is challenging the IMR decision..Change of material facts.

I would really like to hear from someone that their private insurance is acting as a secondary and picking up denied work comp treatment.

I hear it can be done. I would be most appreciative of someone sharing their story of this.
 
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#15
(03-24-2018, 12:35 AM)Shadow Wrote: Just had a MRI denied through UR and IMR ..called medicare yesterday. Spoke to a benefits coordinator about Medicare acting as secondary coverage.

The answer is No! I got nowhere fast after an 81 minute wait time . They cited a US federal code. Said the treatment request was from a work comp provider , reviewed by a work comp ur doctor, and imr doctor . Said my remedy is the WCAB. Talk to your lawyer. Have a nice day.

They will not make any conditional payments .

I got a personal feeling that they have had absolutely enough of California's workers comp system.

My MPN doctor stepped up and is challenging the IMR decision..Change of material facts.

I would really like to hear from someone that their private insurance is acting as a secondary and picking up denied work comp treatment.

I hear it can be done. I would be most appreciative of someone sharing their story of this.

Shadow do you have Medicare as a secondary to private insurance coverage through your spouse? If so Medicare acts as a secondary to that coverage and will not cover anything until it is first covered/processed by your private insurance. Also if you do not have prescription drug coverage under Medicare they will not cover denied WC medications.

I converse with injured workers who are getting WC denied medical treatment covered through Medicare and injured workers who are also getting WC denied treatments covered by private insurance. With Medicare you have to submit written proof of the denial and it entails more than a phone call. You may have to work your way up the ladder with your private insurance and Medicare to find out why you are having such problems getting denied treatment covered.

https://www.medicare.gov/supplement-othe...ments.html
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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#16
It also has to be something that Medicare or private insurance would normally cover. They do not cover everything. Medicare does not cover massage for example.
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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#17
(03-25-2018, 12:06 PM)California_Help Wrote:
(03-24-2018, 12:35 AM)Shadow Wrote: Just had a MRI denied through UR and IMR ..called medicare yesterday. Spoke to a benefits coordinator about Medicare acting as secondary coverage.

The answer is No! I got nowhere fast after an 81 minute wait time . They cited a US federal code. Said the treatment request was from a work comp provider , reviewed by a work comp ur doctor, and imr doctor . Said my remedy is the WCAB. Talk to your lawyer. Have a nice day.

They will not make any conditional payments .

I got a personal feeling that they have had absolutely enough of California's workers comp system.

My MPN doctor stepped up and is challenging the IMR decision..Change of material facts.

I would really like to hear from someone that their private insurance is acting as a secondary and picking up denied work comp treatment.

I hear it can be done. I would be most appreciative of someone sharing their story of this.

Shadow do you have Medicare as a secondary to private insurance coverage through your spouse? If so Medicare acts as a secondary to that coverage and will not cover anything until it is first covered/processed by your private insurance. Also if you do not have prescription drug coverage under Medicare they will not cover denied WC medications.

I converse with injured workers who are getting WC denied medical treatment covered through Medicare and injured workers who are also getting WC denied treatments covered by private insurance. With Medicare you have to submit written proof of the denial and it entails more than a phone call. You may have to work your way up the ladder with your private insurance and Medicare to find out why you are having such problems getting denied treatment covered.

https://www.medicare.gov/supplement-othe...ments.html

Thank you !

I felt like I was being misled by a benefits coordinator . Then I wondered .What if I just had the scan anyway ..wouldn't I have had appeal rights.

Thanks to my doctor .. he is re submitting another RFA for change of material fact. The IMR decision I received is outrageous and erroneous.

I really don't know much about Medicare.

Medicare is a secondary to workers comp FMA . Yes I have prescription coverage Part D that I pay 30 bucks extra a month from a Medicare approved drug company.
 
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#18
(03-25-2018, 04:41 PM)Shadow Wrote:
(03-25-2018, 12:06 PM)California_Help Wrote:
(03-24-2018, 12:35 AM)Shadow Wrote: Just had a MRI denied through UR and IMR ..called medicare yesterday. Spoke to a benefits coordinator about Medicare acting as secondary coverage.

The answer is No! I got nowhere fast after an 81 minute wait time . They cited a US federal code. Said the treatment request was from a work comp provider , reviewed by a work comp ur doctor, and imr doctor . Said my remedy is the WCAB. Talk to your lawyer. Have a nice day.

They will not make any conditional payments .

I got a personal feeling that they have had absolutely enough of California's workers comp system.

My MPN doctor stepped up and is challenging the IMR decision..Change of material facts.

I would really like to hear from someone that their private insurance is acting as a secondary and picking up denied work comp treatment.

I hear it can be done. I would be most appreciative of someone sharing their story of this.

Shadow do you have Medicare as a secondary to private insurance coverage through your spouse? If so Medicare acts as a secondary to that coverage and will not cover anything until it is first covered/processed by your private insurance. Also if you do not have prescription drug coverage under Medicare they will not cover denied WC medications.

I converse with injured workers who are getting WC denied medical treatment covered through Medicare and injured workers who are also getting WC denied treatments covered by private insurance. With Medicare you have to submit written proof of the denial and it entails more than a phone call. You may have to work your way up the ladder with your private insurance and Medicare to find out why you are having such problems getting denied treatment covered.

https://www.medicare.gov/supplement-othe...ments.html

Thank you !

I felt like I was being misled by a benefits coordinator . Then I wondered .What if I just had the scan anyway ..wouldn't I have had appeal rights.

Thanks to my doctor .. he is re submitting another RFA for change of material fact. The IMR decision I received is outrageous and erroneous.

I really don't know much about Medicare.

Medicare is a secondary to workers comp FMA . Yes I have prescription coverage Part D that I pay 30 bucks extra a month from a Medicare approved drug company.


Did you ever hear anything about your doctor's challenge to the IMR? IMRs are almost 96 percent upheld because their in bed with the same folks at the UR. Have you heard the doctors and nurses that write the IMRs work for the Utilization Review too? One of the Applicant Attorney's wrote "It would be strange to have a UR Denial" sent to the IMR Reviewer only to find it on the desk of the same person who denied your claim". I wonder if Maximus uses the same trash the UR does to deny claims?

I read one of my UR Denials and the UR doctor was so corrupt he lied through his teeth. He did not read through my doctor's notes, he lied saying "patient does not random drug tests". "Patient has not shown any improvement with nerve pain medication" even though my doctor's notes contradicted everything the UR doctor said. Its such a rigged system, California has a shortage of QMEs making it take up to seven months to get your appointment with a specialty. Please share how your PTP or other specialist did with your IMR denial. Eventually the carriers will deny all medications because they know the IMRs will blindly follow the "UR Expert" most of the IMR doctors are old or retired.
 
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