Administrative Directors Determination (California) (Califor

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Administrative Directors Determination (California) (Califor

Postby Luckyazkd9 on Tue Jul 05, 2016 6:22 pm

Received a letter from my AA which stated "we have an advisory PD rating of 64% and 94%". Also we have a Administrative Directors Determination which the defendant is now able to work on a full settlement. I have searched AD determination and all I find is how to appeal one. Could someone enlighten me, please. Also my I request the dollar value of the Medicare Set Aside which I am told is an advisory figure?

I thank You in advance for your valuable time and knowledge.
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Re: Administrative Directors Determination (California) (Califor

Postby LawAdvocate on Wed Jul 06, 2016 9:03 am

What type of AD determination? The AD makes all types of determinations.

You can ask for anything, has the proposed Medicare amount been approved by CMS? It might come in higher, so you can agree to a tentative C&R and then the C&R is on hold until CMS approval is received. The alternative is to assure that if the CMS comes in higher, that your insurance company increase the CMS funds for the Medicare set-aside to the amount that CMS approves.
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Re: Administrative Directors Determination (California) (Califor

Postby Luckyazkd9 on Sat Jul 09, 2016 9:48 am

Law Advocate, thank you for your response. I am uncertain as to why type of A/D determination it is. All I can tell you is that it pertains to the settlement process in a workers' compensation claim. Letter received from my AA. used the language.

I shall find out from my AA if the Medicare Set Aside is CMS approved. I am really grateful to have been made adware of the circumstance.

An other sentence reads as: " Because you have both Medicare and Social Security benefits, a settlement of the workers compensation case would be in your best interest". How is it in my best interest? I well know I shall have Medical problems related to my Industrial injuries the rest of my life. Both knees have been replaced and I have four cages in my Lumbar.Failed back surgery is the cause of most of my physical pain.

I Thank You
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Re: Administrative Directors Determination (California) (Califor

Postby LawAdvocate on Sun Jul 10, 2016 2:55 pm

It is in your best interest for one main reason - Medicare has no Utilization review process. Think about that, no physician has to ask anyone else if they like their treatment plan, you get the care as soon as your physician can provide it with no delays and no denials. Now if I could get more Applicants to understand this, it would make the world a better place.


Your Medicare set-aside is also a "compromise and release" with CMS. So once you prove you spent all of that money, are you hung out to dry? NO! Medicare continues to pick up all of your care. So the key is to assure the Compromise and Release contains enough to cover non-Medicare set aside items and you are good. Couldn't ask for more. I personally would prefer Medicare "control" my care than any insurance company. Doctors have much more autonomy under Medicare.

Any Applicant who has a chance to get out from under the utilization review process should jump all over that.

Ask your attorney what type of AD determination was received and for a copy of the determination.
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Re: Administrative Directors Determination (California) (Califor

Postby Barney5 on Mon Jul 11, 2016 6:12 pm

I just want to mention that with Medicare you will be subject to things like co-pays and deductibles that you do not have in work comp. Also, Medicare does not cover everything that work comp covers for example home help and LawAdvocate mentioned to get the MSA to cover things that are not covered by Medicare which is a good idea. Some patients are having difficulties finding doctors in certain specialties who accept Medicare. These are all things to consider.

I agree with LawAdvocate that for most patients getting out of the work comp system with UR and IMR is a good thing.
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