PD rating (California)

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Re: PD rating (California)

Postby dolphines on Wed Jul 15, 2015 10:10 am

Hi everyone.

I was wondering about msa vendors. I noticed there are a lot of them.

Will one vendor come back with a different msa amount than another?
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Re: PD rating (California)

Postby LawAdvocate on Thu Jul 16, 2015 2:49 pm

Yes, if the vendor guarantees the amount prior to CMS approval the amounts seem to be higher.

If the vendor does not guarantee the amount, they seem to come in at a lower number.

You should receive a copy of the MSA - look at the listed services and attempt to determine if any do not apply. NO benefit over what is required for CA workers' comp has to be in a Medicare set-aside so for instance, some vendors but in brand name drugs, however CA law requires generics absent a good medical reason why the brand name is required.

Then we see drugs the Applicant was perhaps prescribed once....so we have to get a statement from the physician saying you are no longer using that and have no used that for ages. Also there should be no medical care for any disputed body part, sometimes the MSAs over reach in this matter. So if it is not something you have used or a physician has said you will need in relation to medical care on a go forward basis, there is from time to time a good cause to dispute. However, once you take it out of the Medicare set-aside, it is not like it ends up in your pocket, so you really have no duty to "fix" the Medicare set-aside as an Applicant. Once it is out of the Medicare set -aside, it is out of the picture for settlement purposes, so you mostly see the employer/insurance company/third party administrator disputing the set-aside values to minimize their risk.
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Re: PD rating (California)

Postby dolphines on Thu Jul 16, 2015 4:07 pm

Thank you LawAdvocate.

I am so confused by this msa. I don't know if everything will be covered, and if CMS will look at all the records themselves, and come up with their estimate and compare it to the one the vendor does, or if they just go by the vendors figures, and the vendor leaves things out to benefit the CA/IC.

And I have no ideal where to begin when it comes to non-medical.

How can I be sure I'm not being low-balled?
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Re: PD rating (California)

Postby LawAdvocate on Fri Jul 17, 2015 8:53 am

Whatever CMS approves for the MSA is all that is owed. IF that money is exhausted and all paid out, CMS takes over for any overage. You really don't have to be concerned with the number, just that it is done with CMS approval

Non-medical is straight up the PD you are owed less advances.

The ambiguous number is non-Medicare items, you have to estimate what you use per year from a benefit printout and then add any one time items. This is an estimate and not carved in stone.
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Re: PD rating (California)

Postby dolphines on Fri Jul 17, 2015 9:42 am

I can't thank you enough LawAdvocate.
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Re: PD rating (California)

Postby dolphines on Sun Jul 19, 2015 8:51 am

Can I provide email's from the CA/DA too and from me, to the deu/wc judge?
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Re: PD rating (California)

Postby LawAdvocate on Mon Jul 20, 2015 3:28 pm

Of no relevance to the DEU. You can list them as evidence on any pre-trial conference statement if they apply to setting a matter to the trial. The DEU offers consultative ratings, which are not final. This is based straight up on the medical reporting and a job description. The DEU if the rating is not accepted for informal settlement purposes is then provided direction from the Judge as to a final rating. So, see no purpose in sending emails to either. If there is a job description and ultimate group number dispute, this is resolved by securing a formal job evaluation with an independent vocational evaluator.
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Re: PD rating (California) (California)

Postby dolphines on Sun Jul 26, 2015 7:40 am

The reason I asked is, I seen a PQME last year, he wrote in his report that there is video showing me walking on my foot, and wearing a walking boot, which would suggest I am not as disabled as I claim.

I contacted the DA and CA, and demanded ALL copies of any/all video, and asked for recipes/approval for said boot, or any evidence that I have ever wore a walking boot.

All of our communication, is by email.

They both sent me a response, saying there is no video that exists, and they know I have never wore a walking boot.

I asked if they sent any video to the PQME, they said no.

I recently went to another PQME, and he commented on the video/boot. He has not completed his report, as medical records are being objected to, and he is awaiting the out come , before he issues his rating.

I want to present those emails to the PQME, along with the courts/deu, and the msa.

Or, can I contact the courts, and have the report throwing out?
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Re: PD rating (California) (California) (California)

Postby Barney5 on Mon Jul 27, 2015 9:19 am

The video should have been included in the exhibit list sent 20 days in advance. Since this did not happen and you believe this to be a video of someone else I would file for a hearing over it. In my opinion the only way to get the report tossed is by a judge. Do you know if the video was sent to your current QME or just the report from the last QME that mentions the video? You may have to request an new QME if this one was biased with a video of someone else. I have read mistakes do happen with sub rosa filming other people.
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Re: PD rating (California) (California)

Postby dolphines on Mon Jul 27, 2015 9:53 am

Thank you.

Should I include the medical records, and the emails from me and the da/ca.
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