California Worker's Compensation - Help For Injured California Workers

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  1. #1
    Join Date
    Feb 2008
    Posts
    2

    Default No Warning Medication Cut-Off, Any Recourse?

    First I would like to say hello and my heart goes out to all of you!!! I'm glad this forum is here.... thanks.

    I live in CA, and was injured in Feb of 2005 on the job. I was recently made P & S. My injury involves my right Scapula pressing on a nerve that's cutting off use of my right arm, and right leg, and its cutting off my extremities through torture, not lack of feeling. This is torture, and I was basically bedridden for 2 yrs. I've been on Fentytnal 100Mgh & Oxycodone for the last 2 years & I hate it. Last year through a referral for In patient pain management I was deemed exacerbated beyond reasonable pharma-ceutical help..... I was denied any help.

    Feb 15th of last week I went to my Doc, he wrote the script, I went to the Pharmacy and they would deliver it in the evening. I get a call at 6:30 that evening telling me that Ive been cut and am no longer going to receive the medication. This was done without warning to me, and almost everybody knows you just don't stop meds like this, yet someone from the insurance carrier is responsible, not to mention what Im going through.

    Are there any options advice or recourse ?

    Regards to all.

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,021

    Default Re: No Warning Medication Cut-off, Any Recourse?

    Welcome to these forums... hopefully you'll be able to find some information here relative to your situation..

    Do you have an attorney handling your claim...?
    What is the status of your claim now...as we have to presume you are P&S/MMI due to your DOI, was there a Stipulated award, or Finding w/Award ordered by a WCAB judge...?
    Are you now receiving regular treatment for your injury, or are you accessing the Future Medical benefits ...?

    As you know, since your DOI is post the changes of 2004, your TTD is capped at the 104 weeks/ 2 years ...

    You are correct that it's not a good idea to stop your med's abruptly, and IF you begin to realize some withdrawal symptoms, PLEASE go to the ER at the nearest hospital, even IF you must use 911/ambulance sevice. If you reach that state, DO NOT drive yourself to the ER.

    Have you made application, or are you receiving SSDA/Medicare... you could use your Medicare to get the Rx filled while you wait for this to resolve...

    Tomorrow, (Monday)contact the CA to find out what is the issue in the denial of your medication...the CA cannot make a denial on her/his own...a request for treatment must be approved, or sent to UR for review.

    Last year through a referral for In patient pain management I was deemed exacerbated beyond reasonable pharma-ceutical help..... I was denied any help.

    How did that resolve... was there an appeal to the denial...?
    Was there a DOR filed for expediated hearing on the dispute..?
    Have you been seen by a Panel QME for a med/legal evaluation ?

    If you can answer these questions it would be helpful in addressing your situation ... Charles and pLA will be along shortly.. we'll go from there.

    Hang in there...

  3. #3
    Join Date
    Feb 2008
    Posts
    2

    Default Re: No Warning Medication Cut-off, Any Recourse?

    BvIA, Thanks for the reply, and the questions..... I will get back with the most accurate answers possible after a Functionality Personnel does an over the phone history in about 15 minutes. I will say that my case has been nothing short of a farce, and the one question I'll answer now is when I was bedridden in torture and really required In-Patient care, it was denied. I went to the ER 3 times in 10 days (about 12 times total at ER since 2005 while waiting about 4 hours), now I go to my original non WC PCP for a hipshot about every 3 weeks (7 or 8 times total so far) no appt or waiting necessary . Before going back to him, I was going to the ER for the shots at least once a month, that's even while taking my meds....... gtg

    Ill work on those questions when I'm done giving the umphteenth history.

    If I didn't have a wonderful wife & 2 beautiful kids 4 & 18 months, I'd be hangin alright

    Thanks!!

  4. #4
    Join Date
    Feb 2007
    Posts
    550

    Default Re: No Warning Medication Cut-off, Any Recourse?

    Hi Changed,

    Welcome to the forum.

    What exactly is your injury/diagnosis??? I cannot find ANY nerve that the scapula could press on that could possiby cause you leg issues. (RSD/CRPS, maybe?? incomplete quad?)

    And, congrats on the baby!! SO, it appears the important parts of you work.

    Did you see an AME or a QME? If so, what did the report say? If your MEDS WERE DENIED ON THE 15th, DID YOU CALL TO find out why?


    If you can address BV's question so we can assist you more.


    LA

  5. #5
    Join Date
    Feb 2008
    Location
    Gillette,Wy
    Posts
    99

    Default Re: No Warning Medication Cut-off, Any Recourse?

    I have a pain management dr. that likes to make major decisions concerning my meds, without including me also. fortunetly, he works for my surgeon and i just have to call my surgeon and he can usually straiten it out. do u have a good pharmacy? mine is a small business, real small town people, and they have helped me in shitty situations before. offer to pay for it yourself. they are usually most concerned with getting paid. i hope this helps.

  6. #6
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,021

    Default Re: No Warning Medication Cut-off, Any Recourse?

    ''...offer to pay for it yourself. they are usually most concerned with getting paid. ''

    serve,
    The pharmacy is actually concerned with staying within the law...
    pharmacy's in Calif, have been 'formally' notified by the Dept of Ins. director that asking for payment/or allowing an IW to pay up front for medications in a industrial injury is illegal and there can be fairly big fines for doing so.

    I realize it's not in an IW head what is ''legal or illegal'' when you are out of pain medication, and there are certainly drugs that you should not stop suddenly, but IF this is the case you go to the Emergency Room at the hospital, or Immediate Care facility for help until you can get the problem cleared up. Particularly if the drug is a 'controlled substance''.

    The doctor is wrong to issue a new Rx for a drug that may require pre authorization by the IC.
    The IC is wrong to deny a re-fill on a drug where the IW has been taking it for a extended period of time. And a CA is WRONG to issue a denial of ANY treatment as ONLY a doctor can legally deny/modify/delay a requested treatment.

  7. #7
    Join Date
    Feb 2007
    Posts
    550

    Default Re: No Warning Medication Cut-off, Any Recourse?

    BUT, SHIT happens!!

    NONE of the Pharm's I have been dealing with have REFUSED to accept payment from my IW's when their meds were denied. One pharm said, "fu the IC's", and any state statute that would prevent them from helping an IW who WILL suffer from medical problems if 1) narcotis/opiates are abruptly stopped 2) Anti-Seizure meds are abruptly stopped 3) Anti depressants are abruptly stopped (ESP SSRI's) 4) Tranq's.

    Although I do advise my Iw's to go the the ER, if they are TOTALLY OUT of meds, and it looks serious, i would prefer to have the meds paid for, first. I have seen IW's labelled as drug seekers when they present to the ER. (Look at Georger from WCC) That is the death knell for many chronic pain patients. Once a DA gets hold of that opinion info, an IW is usually put through hell. I have seen reports from Defense "Ladies of the Evening" that totally destroy the credibility of an IW. Once a bell is rung, it cannot be unrung.
    My opinion....

    The statute that prevents IW's from paying for med tx is on the books to prevent IW's from being exploited. Keeps unscrupulous Dr's/ pharms from collecting fees. I can't imagine prosecution where it was done to assist an IW.
    Steve, do you have info on the letter sent to Pharms? I would be interested in taking a look at it.

    LA

  8. #8
    Join Date
    Dec 2006
    Posts
    2,165

    Default Re: No Warning Medication Cut-off, Any Recourse?

    PLA is right on...abruptly discontinuing certain medications can be downright DANGEROUS. Its far more "cost-effective" for the IW to pay out of pocket for meds, and the Pharmacy to accept payment, and a HELL of lot less expensive that a trip to the ER and the "attendent problems" of being labelled a "drug-seeker"..

    What would the LEGAL ramifications be to a Pharmacist who REFUSED to accept payment from an IW for a PRESCRIBED MEDICATION, KNOWING that there could be VERY serious ramifications or possibly DEATH?

    I agree that the law intended to protect IWs from being exploited...there ARE some "unscrupulous" paharmacists out there who have CONTRACTS with ICs, and accordingly, the medication costs are far cheaper. Knowing this, the "unscrupulous" pharmacist , when an IW shows up to get there meds, only to find out at the pharmacy counter that their meds are abruptly DC'd by the IC for a WC claim, CAN be exploited by the pharmacist by charging the IW FULL RETAIL COST, and NOT the CHEAPER "negotiated CONTRACT" price of those medications...THOSE pharmacists SHOULD be penalized...

    NO pharmacist that I am aware of has REFUSED to accept direct payment from an IW when their meds have been abruptly DC'd by WC.

    That letter that BvIA refers to would be interesting indeed to read....

  9. #9
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,021

    Default Re: No Warning Medication Cut-off, Any Recourse?

    I'll have to find it... I read it in the newspaper when Garimendhi issued the warning, and I talked to my pharmacist and read the letter she received...that was a RiteAid Rx...there were two independant Rx's that had the same letter. And a friend of mine who had a very old claim, but was still receiving med's was told the same, and the Rx would not accept the pre payment from him.

    I don't believe I said it would be 'illegal' for the IW to prepay... but it IS illegal for the pharmacy to ask for payment.
    The whole thing boils down to the ER/IC NOT having to reimburse the IW's for meds that are pre paid at a fee schedule other than the OMFS...

    I'm not arguing the points you cite, they are valid...no IW should have to be reduced to the ER because the meds have been denied by the IC....sadly, the CA's are still denying refills knowing full well they are NOT legally allowed to do so. The third party authorization co's (not "TPA", but those like RxSolutions etc) are also denying based on erroneous information provided by the CA's. The biggest problems occur on the weekends when there is no one available to rectify the situation IW's are potentially facing at the pharmacy.

    The biggest problem was/has been those pharmacy's that have asked the IW to pre pay for the medications and ask the ER/IC for reimbursement... THAT is what is the basis for the "legality'' of the issue...The ''cost'' to the ER/IC vs the OMFS.

    This is from the Dept of Ins web site...http://www.insurance.ca.gov/0100-con...fo-general.cfm, bottom of the page...
    ''Important Notice to Injured Workers: Have you filed a current workers' compensation claim and your pharmacy is asking you to pay for your prescription drugs? If you are an injured worker who has a current workers' compensation claim and your pharmacy is asking you to pay for all or part of your prescription drugs, Insurance Commissioner Steve Poizner wants to hear from you! Please call or e-mail the California Department of Insurance at 1-800-927-HELP or visit our "Contact Us" site Consumer HOTLINE at 1-800-927-HELP. Identify yourself as an injured worker who is being required to pay for prescription drugs. We will forward the information to our general counsel and work in conjunction with the Department of Industrial Relations to get relief for you.''

    It's not the IW who is breaking the law... it's the pharmacy...and the DIR and the CDOI are going after pharmacy's that ask for payment to go around the fee schedule. Steve Poizner is calling the practice 'fraud', the pharmacy is attempting to 'defraud' the ER/IC by charging a 'uaual and customary' fee for the drugs, vs that provided in the OMFS.

    I can't blame the CDOI for stopping the practice of having an IW pre pay for a medication... I went to a Rx to pick up refills...out patient, same Rx I used for several years. I asked for a printout of the meds/cost for my AA...there was one drug that I recognized as having a cost of about $765. +change, when I got the printout that drug was listed as having been billed to the IC at a cost of $1768+change...ONE THOUSAND DOLLARS difference.
    When I questioned the 'new owner' on this descrepancy I was told the previous owner was not charging the correct amount for the medication...and IF I didn't have the IC paying I would have to prepay that amount and get reimbursed...period. (this was a hospital pharmacy) When I asked about the guy who didn't have the IC how much would be charged I was told $1768+change...(I didn't go back to that pharmacy again, but that's not the point).
    The price at RiteAid was $728.00 (about)...and consistent monthly, and the benfit printout from the CA matched the price I was quoted by the Rx.

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