from Medicare to MPN? (California)

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from Medicare to MPN? (California)

Postby beach7 on Tue May 07, 2019 3:01 pm

Applicant decided to self-procure from Medicare instead of using the MPN. Then Medicare keeps adding to a huge lien that it sends to the claims office and demands payment which causes many complications in resolving. Can an applicant be forced from Medicare into the MPN? What else can claims office do to prevent this?
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Re: from Medicare to MPN? (California)

Postby LawAdvocate on Wed May 08, 2019 8:19 am

You go to court and force an Order that unless care is denied,the Applicant must treat within the MPN. Be prepared to evidence that you are entitled to have the person treat within the MPN as well. If the treatment is non-certified by UR, the Applicant is entitled to treat with Medicare and you will most likely have a lien to resolve at the end.

If you do not have that evidence, you must prepare a transfer into the MPN which includes notifying the current physician, setting up an appointment with an MPN physician and notice.
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Re: from Medicare to MPN? (California) (California) (California)

Postby beach7 on Wed May 08, 2019 4:42 pm

He's going to medicare for the sole reason that he prefers their docs and not bc of any UR denials. Must he treat in the MPN? I believe there is a code section that an applicant has a right to self-procure whatever treatment he wants at his own expense and own risk. I don't have that code handy but there is something there to that effect. Regardless, do you think a judge would actually issue an order for one to use only the MPN? Or else what? The judge will dismiss his entire case including his medical award? Is that what you're saying?
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Re: from Medicare to MPN? (California)

Postby jpod on Fri May 10, 2019 11:48 am

"...He's going to medicare for the sole reason that he prefers their docs and not bc of any UR denials. ..."

Doesn't that change things if the doctor is billing CMS for treatment for a WC claim for treatment that was not denied via UR/IMR? Medicare is not primary insurance.

Wouldn't it behoove the adjuster to write to the PTP, providing notice of the doctor's duty as the PTP? The regs say "any physician" - a physician who is treating a patient for a workers' comp injury is subject to the all the statutes and regs. unless I suppose if the doctor is treating under LC 4605. I'd try to get the doctor's attention and acknowledgement that he/she is treating under LC 4605 which could help when CMS tries to collect via lien.
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Re: from Medicare to MPN? (California)

Postby mk61347 on Mon May 13, 2019 1:15 am

The adjusters job is to manage the cost of the claim for the insured. Why would the adjuster try to incur more expense for their client . It is not the adjuster's job to tell the pcp his responsibilities on his ethics. Am i missing something (besides a brain)
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Re: from Medicare to MPN? (California)

Postby mk61347 on Mon May 13, 2019 1:22 am

I am not an attorney, but i do not understand why the potential liability for medicare's bill would not be the patients for going outside the workers comp systen when the insurance carrier did not deny treatment.
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Re: from Medicare to MPN? (California)

Postby mk61347 on Mon May 13, 2019 1:23 am

I am not an attorney, but i do not understand why the potential liability for medicare's bill would not be the patients for going outside the workers comp systen when the insurance carrier did not deny treatment.
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Re: from Medicare to MPN? (California)

Postby lacompfun on Mon May 13, 2019 7:55 pm

Expedited on MPN. When defense wins the applicant would arguably be liable .

Expect to resolve by stip award or trial .
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Re: from Medicare to MPN? (California)

Postby beach7 on Tue May 21, 2019 4:12 pm

from what i've heard the way it works is the IW is MIA until the claims office discovers through its vendor that there is some type of Medicare lien that claims thinks it need be paid. From legal perspective I've never understood how medicare plans on collecting on its "lien." Couldn't the I.C. just deny this lien outright and then what? is Medicare going to sue in federal court? I've never heard of that but maybe i missed it. Arguably there is no ripe issue to do anything until Medicare takes some action to collect and I'm not clear how it thinks it would go about doing that. But i'm not sure how the issue shows up to I.C. Wouldn't the I.C. defend by saying the treatment is non-compensable and they need to seek recourse from the I.W.? The I.W seems to be the one at risk of wrongfully using Medicare - the I.C. isn't a babysitter for every person with an open medical. I agree that besides the standard notices advising to use only the MPN, it's not clear to me why claims would necessarily need to take any affirmative action to get the treatment into the MPN, as a) it's not ripe; and b) wouldn't that just be putting more costs onto the themselves.
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Re: from Medicare to MPN? (California)

Postby jpod on Wed May 22, 2019 8:27 am

My comments were based on the original post that stated the WC insurer was aware the employee was treating outside the MPN and billing Medicare. My recommendations were designed to lay a paper trail that doctor and employee were advised of their duties under the labor code and that any liability to Medicare would fall to them.

I agree with the post that recommended an expedited hearing on MPN which if it prevails would be a judicial finding that the EE has to treat within the MPN which CMS would have to honor; and which would further make employee and doctor aware that their excursion/deviation/abandonment of the worker's comp claim could have repercussions.
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