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primary care faciolity denies service
#1
hi everybody, i'm Dave from (and currently in) Texas. i was hurt on the job in Texas in Feb of 2007. My employer had worker's comp. insurance through Cambridge. immediately after the injury i called my employers and they took me to an emergency clinic, where i was xrayed and diagnosed with back strain, given tramadol and celebrex, and told to report back weekly, which i did.

the pain, which was quite sever, did not get any better for months, finally i was given an MRI and diagnosed with a herniated disk, and sent to a neurologist who did an electrical nerve test and diagnosed me with radio culpathy (pinched nerves) which was a result of the disk herniation.

i was sent to a pain specialist, and when i requested something that would ease the pain better than the tramadol and celebrex, while waiting the several weeks untill the injection date, was accused of wanting narcotics. I told the insurance people the accusation was true, that in fact i did want narcotics, as the tramadol was not addressing the pain, and giving me terrible heartburn, which i still have, even though i stopped taking the tramadol and celebrex months ago.

so i found another pain specialist, told the insurance people, who contacted my primary care doctor, and a referral was arranged. it was decided that steroidal injections were the solution, and even though i explained the tramadol and celebrex wasn't working, and in fact adding to my pain (via the terrible heart burn) was given the strong ibuprofen tablets, and tramadol, and celebrex.

it took several weeks before the injections were administered, this some 5 to 6 months after the injury, and by that time the paralyzing pain had diminished greatly, but there was still a lot of discomfort.

so the injections, a series of two separate events, did not really relieve any pain, yet i can not know that if they had been administered sooner after the injury would, or would not have. it would have been a God send if the agony of those several months could have been relieved, but i do not know that it could have, simply because nothing tangible as far as pain management occurred when the pain was at its most intense.

interestingly enough, the pain doctor, upon my final visit with him before being released told me to NEVER take celebrex and ibuprofen together. I thought this odd since it was his staff who prescribed me the ibuprophen and celebrex together, adamantly refusing to give me anything that would actualy relieve my pain. I jus find it odd, that all the time, and complicated procedures, and hours of paper work and phone calls to insurance people and accountants, and lawyers did not help the situation at all, and that i could have been spared months of quiet sever agony by being prescribed hydrocodone and cyclobenzaprine, not to mention a ton of money, and their time could have been saved.

during this time, being very frustrated, and by some miracle, i managed to find an attorney who took the (my) workman's comp case. also i reapplied for social security disability (which i had applied for in 2004 with no success).

The main reason i got the attorney was because in all correspondence with the work comp insurance people, they were determined to call my injury a "strain" and not a "herniation". since it was defined a "lost time accident" i received an approximately $100 check weekly. once the injections occurred, the insurance people stopped these lost time checks. the attorney arranged for me to see a state certified (texas) doctor to evaluate me, and after two separate visits with him, it was determined that the injury was due to the job, and i was awarded 5% disability. which resulted in the insurance people giving me a $1500 settlement.

in the mean time i was approved for social security disability, from which the work comp money was deducted. but the work comp insurance company said they would always be liable for any treatment (pain management) my condition would require.

my condition gives me constant pain, but all the doctors stopped authorizing the tramadol, celebrex, and ibuprofen prescriptions. and since the added, terrible heart burn that started soon after i started the tramadol and celebrex was no help, i simply did with out any medication. while the herniation and degenerated disks are a constant discomfort, it was tolerable and i managed it with over the counter medications.

the other morning (6 or so days ago) i woke up and when i tried to get out of bed, the pain was intense, and debilitating. i am on social security disability, but the medicare doesn't start till august (three more months). I went a couple days hoping it would get better, but it did not, and hasn't.

I went to my primary care doctor, and they said i was not entitled to further care from the work comp insurance. However, the work comp insurance people say they will always be liable for the treatment of this injury.

being at a loss for options, and desperate, i went to the emergency room of a local hospital and was given an injection and a prescription which has relived my pain wonderfully. however, now, i am liable for the cost of this treatment and the medications.

the sad thing is, in a few weeks my medicare insurance starts and i will have access to a doctor, this current situation though is pretty bad, i have many things to do, and need to be able to do them, and the pain in my back simply wont let me. thankfully the doctor at the emergency room saw and had mercy, and gave me what i needed to function adequately.

ok, that's basically the background, I am just wandering what the law actually is, is the worker's compensation insurance company actually liable for the cost of whatever treatment the condition requires or not?

frankly, i do not want to rely on worker's comp, because the treatment they give involves mostly paper work, and vague diagnoses, and most doctors don't want to mess with it, simply because the trouble is much more than the benefits. however, since they told me they were liable for my injury's treatment, i feel as if at the very least the primary care doctor they gave me should treat me when i need it.

Does anyone understand?

thanks,
Davey
 
Reply
#2
Usually, when one gets approved for SSD & gets medicare, Medicare demands a set aside money from WC to cover any future costs for your injury.....as Medicare is not the responsible party to pay....so they get this "pot" from wc to use in case you need more trestment. Was a set aside done when you were awarded SSD?
Lilly
Injured worker, & tired of it all! I'm too old for games!!

A careless word may kindle strife, a cruel word may wreck a life, a timely word may level stress, and a loving word may heal and bless!
 
Reply
#3
daveybaby52 Wrote:hi everybody, i'm Dave from (and currently in) Texas. i was hurt on the job in Texas in Feb of 2007. My employer had worker's comp. insurance through Cambridge. immediately after the injury i called my employers and they took me to an emergency clinic, where i was xrayed and diagnosed with back strain, given tramadol and celebrex, and told to report back weekly, which i did.

the pain, which was quite sever, did not get any better for months, finally i was given an MRI and diagnosed with a herniated disk, and sent to a neurologist who did an electrical nerve test and diagnosed me with radio culpathy (pinched nerves) which was a result of the disk herniation.

i was sent to a pain specialist, and when i requested something that would ease the pain better than the tramadol and celebrex, while waiting the several weeks untill the injection date, was accused of wanting narcotics. I told the insurance people the accusation was true, that in fact i did want narcotics, as the tramadol was not addressing the pain, and giving me terrible heartburn, which i still have, even though i stopped taking the tramadol and celebrex months ago.

so i found another pain specialist, told the insurance people, who contacted my primary care doctor, and a referral was arranged. it was decided that steroidal injections were the solution, and even though i explained the tramadol and celebrex wasn't working, and in fact adding to my pain (via the terrible heart burn) was given the strong ibuprofen tablets, and tramadol, and celebrex.

it took several weeks before the injections were administered, this some 5 to 6 months after the injury, and by that time the paralyzing pain had diminished greatly, but there was still a lot of discomfort.

so the injections, a series of two separate events, did not really relieve any pain, yet i can not know that if they had been administered sooner after the injury would, or would not have. it would have been a God send if the agony of those several months could have been relieved, but i do not know that it could have, simply because nothing tangible as far as pain management occurred when the pain was at its most intense.

interestingly enough, the pain doctor, upon my final visit with him before being released told me to NEVER take celebrex and ibuprofen together. I thought this odd since it was his staff who prescribed me the ibuprophen and celebrex together, adamantly refusing to give me anything that would actualy relieve my pain. I jus find it odd, that all the time, and complicated procedures, and hours of paper work and phone calls to insurance people and accountants, and lawyers did not help the situation at all, and that i could have been spared months of quiet sever agony by being prescribed hydrocodone and cyclobenzaprine, not to mention a ton of money, and their time could have been saved.

during this time, being very frustrated, and by some miracle, i managed to find an attorney who took the (my) workman's comp case. also i reapplied for social security disability (which i had applied for in 2004 with no success).

The main reason i got the attorney was because in all correspondence with the work comp insurance people, they were determined to call my injury a "strain" and not a "herniation". since it was defined a "lost time accident" i received an approximately $100 check weekly. once the injections occurred, the insurance people stopped these lost time checks. the attorney arranged for me to see a state certified (texas) doctor to evaluate me, and after two separate visits with him, it was determined that the injury was due to the job, and i was awarded 5% disability. which resulted in the insurance people giving me a $1500 settlement.

in the mean time i was approved for social security disability, from which the work comp money was deducted. but the work comp insurance company said they would always be liable for any treatment (pain management) my condition would require.

my condition gives me constant pain, but all the doctors stopped authorizing the tramadol, celebrex, and ibuprofen prescriptions. and since the added, terrible heart burn that started soon after i started the tramadol and celebrex was no help, i simply did with out any medication. while the herniation and degenerated disks are a constant discomfort, it was tolerable and i managed it with over the counter medications.

the other morning (6 or so days ago) i woke up and when i tried to get out of bed, the pain was intense, and debilitating. i am on social security disability, but the medicare doesn't start till august (three more months). I went a couple days hoping it would get better, but it did not, and hasn't.

I went to my primary care doctor, and they said i was not entitled to further care from the work comp insurance. However, the work comp insurance people say they will always be liable for the treatment of this injury.

being at a loss for options, and desperate, i went to the emergency room of a local hospital and was given an injection and a prescription which has relived my pain wonderfully. however, now, i am liable for the cost of this treatment and the medications.

the sad thing is, in a few weeks my medicare insurance starts and i will have access to a doctor, this current situation though is pretty bad, i have many things to do, and need to be able to do them, and the pain in my back simply wont let me. thankfully the doctor at the emergency room saw and had mercy, and gave me what i needed to function adequately.

ok, that's basically the background, I am just wandering what the law actually is, is the worker's compensation insurance company actually liable for the cost of whatever treatment the condition requires or not?

frankly, i do not want to rely on worker's comp, because the treatment they give involves mostly paper work, and vague diagnoses, and most doctors don't want to mess with it, simply because the trouble is much more than the benefits. however, since they told me they were liable for my injury's treatment, i feel as if at the very least the primary care doctor they gave me should treat me when i need it.

Does anyone understand?

thanks,
Davey

Davey wow were you approved for social security the first time you applied. With only 1 herniated disc it sounds suprising that your were able to get SSD. You are one lucky person then.
Cervical Fusion 2003, c5-c6. Herniated and damaged Disc L1- L4-L5 S1. Lumbar Spinal Cord stimulator implant 09-2008. Cervical ACDF revision with hardware c4-c5-c6-c7 Sept 2009.
SSDI approved 3-2010. NOW OFFICIALY RETIRED
 
Reply
#4
In the state of Texas, WC is to pay for all remaining medical, even after being found MMI and receiving a settlement. I would call the adjustor for the IC and find out why you are being denied care for a continued medical condition.

Also, while you wait for medicare to kick in, you can apply for medicaid since you were found disabled by SS. It will cover up to three months worth of past medical bills if approved. I was turned down for it..although I am on long term disability through my employer and there is no way in hell that I can come up with 1700 for cobra by June 7th to get it started. Why in the heck do you have to pay for months of cobra that you don't get to use ?? But... I'm not disabled by SS standards, so therefore.. I have no insurance, my 63 days are up and I will never be able to get private insurance again because of my pre-existing conditions, and can't get medicaid, because I am single, white and of working age with no dependents at this time ( As of June 2nd that is changing when I get custody of my 15 year old son) but until he has lived here for 6 months, he doesn't qualify as a dependent.

I hope that you can get this straightened out.

Angel ^j^
I've always been crazy, but it keeps me from going insane.
************
Happiness comes through doors you didn't even know you left open
 
Reply
#5
Dear Lilly and Angel J,

first, forgive me for misspelling "facility" in the subject line *smile*. dang spell checker didn't check that an i don't see to good.

i do not know if Medicare, or Medicaid "set aside" any funds from WC. I was told by my advocate that i would have Medicaid for a few months upon getting disability. But i never used it, was never contacted by, or had any discussions with Medicaid as I didn't need it at the time. I assume the time limit has passed for it anyway, but i will call my advocate, and perhaps Medicaid to find out. It seems like the lady at the billing desk at the ER would have advised me of any options since i informed them of the situation.

I emailed the Hospital this morning with all the dates and contact information concerning the WC in my case. Of course this is a holiday, so I'm sure no one in billing is there. Also, its the weekend so i doubt I'll hear anything till next week.

one good thing is its Friday so i may win the lotto *smile*, but of course, i wont be able to collect till next week either LOL.

I guess I'm going to have to call the IC (insurance company?) adjuster to find out. Frankly, i don't want to talk to them because it was a very unpleasant experience in dealing with them. But I am concerned, even though I've always had back trouble, its never just started hurting like this, and this sever before. Before it was always from doing something, this time is different. I may need those steroidal injections again.

It was funny, i went into the ER and went to the front desk, the lady asked me my name, address and phone number. Then i was told to go to another desk, and upon doing so, i was asked my name address and phone number. Then i was taken to a room to wait for a doctor. While there this guy with a rolling desk thing came in, and guess what he asked me? Thas right, my name, address, and phone number LOL. i duno, that jus seems real odd to me. i try to avoid doctors an hospitals, cause thas where the viruses go, but it seems like a person should be able to tell "admissions" all that and that info should be available to everyone else. i guess they didn't believe me *smile*.

i will say one thing, the actual doctors and nurses were great. i think the solution to the health care probs in the USA is to get rid of everybody in the system who does not provide medical care. we would save a ton of money, and to be honest, all the insurance companies and profit seekers in health care do nothing but burden the healers, and those who need healing.

yee haww,
Davey
 
Reply
#6
As far as what LILLY said, she is correct except not in TEXAS. In Texas, the medical coverage for the injury is for life and paid by the IC and not medcare or medicaid. The question I have is why the IC is not paying for your medical care.

My injury was back in 8-05. I to was approved for SSDI. The IC is paying for my meds every month and two drs. visits every three months unless I need to see them sooner.

I am still stuck on the question as to why they are not paying. You can contact your local WC office and ask them whats going on.

Maybe you nedd to speak with your treating dr. and ask whats going on.

Take Care
8-05, Micro laminectomy/disectomy. 10-05 lumbar fusion L5-S1. 2-07 exploritory surgery. 12-07 medical implant, Spinal Cord Stimulator. now receiving SSDI. After going back to school, I received my degree as a mechanical engineer. What can I say, it was the only way I had to beat the system. 
 
Reply
#7
to the person commenting on my being approved so quickly. no, this was the second time i applied, the first time was in 2004; and i went all the way to the judge. that time i had no current medical history, but i knew there was a prob and it was just a matter of time before i would be unable to work. its a shame the judge and ss doctors didn't agree then; cause now the damage is permanent.

it took me an hour to get out of bed this morn, woke up having severe pain spasms. it took another hour to get dressed, and put shoes on, now i'm jus waiting on a ride to er. i don't think i can drive myself like i did Thursday.

to AQA, yes i know the ic for work comp is liable for life, all the paper work they sent me says they are. which is why i don't understand being denied service from the primary care facility. actually i know why nobody wants to mess with it. the reason is, its such an enormous task managing all the paper work, and waiting on the money from the ic.

that's why i got on this forum, as a way to express my dismay, and yes anger. this whole experience has been incredulous, work comp trying to get out of their responsibilities, and the doctors trying to get out of the nightmare the insurance companies create to keep from paying the bills. its a vicious circle, and the sad facts are, if social security had listened to me back in 2004, i probably wouldn't be in this situation now.

anyway, i am in real bad shape this morn, everytime i move my back goes into these agonizing spasms, and i don't know how i'm gona get out to the car. used to i could crawl, but i don't think i can now.

but i aint dead yet LOL, and Lord willing i can get the pain down to tolerable levels. my only concern is i don't have the money, the thousands of dollars they charge... but hopefully the hospital an the ic and work comp folks can work it out.

anyway thanks for all you guys help an comments, there's actually more to be thankful for than there is to not be.

so yee haww,
Davey
 
Reply
#8
Hey AQA...thank you for setting me straight! Texas must be one strange state in regards to WC!

Davey...please be aware that most all injuries are called strains by WC. I had a shoulder dislocation and sublux problems...but WC still called it a strain.

Lilly
Injured worker, & tired of it all! I'm too old for games!!

A careless word may kindle strife, a cruel word may wreck a life, a timely word may level stress, and a loving word may heal and bless!
 
Reply
#9
hey Lilly, yes the ic is in it for profit, i heard or read a while back the only profits they realize is by not paying claims. which brings up a point i was trying to make earlier, there should be no profit motive for the medical industry. better put, all the money that comes into the health industry, stays in the health industry, no need to be siphoning the resources off into investor's accounts.

of course, i see no prob with a private health industry, but there should be a public one too.

some would say the profit motive fuels inovation, and competition keeps costs down. but much of the medical technologies research and development were funded by government grants, and done at our universities. in otherwords it is taxpayer money that established much of what we have.

as to competition, i think it is a poor substitute for a sincere desire to be a healer. i think the engine of innovation and improvement comes from a desire to heal, not get stinking rich.

but like i also brought up earlier, the doctors, nurses, and technicians should be paid well, its not them who are the prob, its the accountants and lawyers that have the system all out of whack. but what good is immovation and improvement that no one can afford?

basic health care should be the norm, not the exception, and we could do it too, if we can get the rats (speculators/investors) out of the seed. ultimately all they do is take money OUT of the healthcare economy. we have let the money grabbers fool us. the spirit of healing, the desire to help others is where the real energy is.

but the only way it can work is if it is a national effort undertaken by "we the people".

anyway i jus got back from er, was given new meds, and flexoril, i guess to get the inflamation done, as he scheduled an mri for next week.

so i'm feeling much better than i did this morn. i sincerly hope your feeling good, you and everybody. i'll pray fer you guys, it works, it jus is real hard having faith sometimes, but faith will get us through.

so... yee hawwww,
Davey
p.s. is it against the rules to post links to personal pages, like say my myspace?
 
Reply
#10
Hi Davey
I would not advise you to post a link to any personal page that reveals your name or whereabouts. We do have private messaging here on this forum, and you could give that info to the people you want & trust to give it to.

Wishing you a pain free day! LillySmile
Injured worker, & tired of it all! I'm too old for games!!

A careless word may kindle strife, a cruel word may wreck a life, a timely word may level stress, and a loving word may heal and bless!
 
Reply
  


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