AME report longevity (California)

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AME report longevity (California)

Postby Luckyazkd9 on Sat Jun 24, 2017 9:51 am

Quick summary. I was injured in 2000, 2x back surgery, both knees replaced and both rotor cuffs repaired. I have never settled as my AA is not really actively pursuing settlement. AME report dated 2011, in the Continue Medical sections reads as : patient should continue to be provided with necessary prescribed medication and future Doctor visits. Prescribed medication were provided until Sept. of 2016. At this point every prescription was submitted to UR and of course denied. IMR appeal was futile according to my AA. My question is, since both parties agreed to accept the finding and treatment plan of the AME may I claim a breech since insurance company has elected to not honor the AME 2011 report? I have not been examined since other them my quarterly PTP visits. I have requested my AA request a court hearing in regards to the med's. Pharmacy is still filling my Primary Care Physicians prescriptions under a lien however I realize the Pharmacy as a business has a lien limit. My PTP had told me I shall need these drugs for the reminder of my life. Any input would be appreciated.
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Re: AME report longevity (California)

Postby Barney5 on Sat Jun 24, 2017 2:35 pm

Before 1/1/2013 and SB863 it was your AME who could decide treatment disputes, however now the process is UR and IMR who makes the determination. Many injured workers who have AME reports that lays out future medical treatment are very upset when they are now denied the things that they thought and were told they would receive. Your attorney cannot file for a hearing if the request was not sent through the appeals process with IMR. If IMR made a mistake for example, or did not review the records then your attorney could have filed for a hearing. If you receive a UR denial I suggest always try to appeal it with internal UR appeal and then with IMR. You could have included the AME report for example when sending records for the appeal. The days of having a judge decide treatment disputes is over since the passage of SB863, well only in certain circumstances with IMR .

I am surprised this pharmacy is providing medications on a lien, but glad you are receiving treatment. There is a 95% denial rate with IMR, however there is another appeals process and that is internal UR review. Your doctor could have tried to appeal it there and maybe he did. I disagree with your attorney to just not attempt the appeals process. If your condition changed your doctor can send the request to UR again before the 12 month waiting period. To receive any type of treatment these days in the CA WC system you need a physician who knows the treatment guidelines and who will help with appeals when needed.

If you have received a denial through work comp and you have Medicare or other insurance you can ask if they will approve it. There are many California injured workers who use Medicare after they receive a denial for treatment with work comp, just make sure Medicare is aware of your work comp case and the denial.
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Re: AME report longevity (California)

Postby chirple on Sun Jun 25, 2017 8:46 am

A really good a/a will review the UR and IMR denials and determine where the weakness is in the RFA issued by the PTP. Then educate the PTP to write an appropriate RFA. If you really need the medications, and it is supported by MTUS, your PTP needs to bone up on MTUS and issue a solid RFA with supporting information in the RFA. I'm seeing that the great majority of denials are due to incomplete, or weak RFA.

UR: UTILIZATION REVIEW
IMR: UR appeal to Independent Medical Review
RFA: Request for Authorization
PTP: Your treating doctor
MTUS: Medical Treatment Utilization Schedule

The best, and quickest solution is to have the treatment authorized the first time, by a really good RFA.
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Re: AME report longevity (California)

Postby Luckyazkd9 on Mon Jun 26, 2017 8:10 pm

Barney5 and Chirple, Thank You, for your responses. I shall schedule a sit down with my AA and PTP utilizing your suggestions. My AA was approaching the Winter of his life when I hired him and with the passage of sixteen years what was urgent for him then, may not be so urgent now. One more question. If MSA totals are based on the Medical costs of the past two years and on the Insurance records I have received zero drug costs for the past ten months how does it affect my MSA totals? An other subject for my AA.
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Re: AME report longevity (California)

Postby Barney5 on Thu Jun 29, 2017 1:31 pm

I am sorry I am not very familiar with MSA's. Are you no longer taking the medications or is another entity paying for them? I have read MSA's can be negotiated especially if something is not correct. So if it comes back with the medication estimate, your attorney can state you no longer take it. Discuss this with your attorney. I assume you want the smallest amount possible for your MSA as it only benefits Medicare.
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Re: AME report longevity (California)

Postby LawAdvocate on Tue Aug 01, 2017 8:16 am

MSAs are a projection of probable costs. They do not limit you to MSA benefits or specify what you spend your Medicare set-aside funds on, if it is a Medicare covered expense, so if you suddenly need medication that Medicare would have covered, you are covered. Therefore, if you exhaust what ever they say on the MSAs, Medicare takes over and you have no worries.


Recall MSAs do not cover everything, they only cover what MSA should have covered. There should be additional sums in your future medical care for non-Medicare covered items.
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