California Worker's Compensation - Help For Injured California Workers

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  1. #1
    Join Date
    Sep 2009
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    CA
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    6

    Default Future Medical Care

    Does anyone have a story how keeping their future medical has actually helped them? From what I am reading, it is a fight even after the judge rules that you are entitled to future medical care. For example, if the judge rules that you should receive future PT and surgery if needed as part of future medical care, how do you go about accessing it? Thank you.

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
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    Default Re: Future Medical Care

    For example, if the judge rules that you should receive future PT and surgery if needed as part of future medical care, how do you go about accessing it?
    Everyone forgets the actual meaning behind ''if needed''. Your PTP still must submit a request for treatment, per the MTUS/ACOEM treatment guides, and the UR process. Just like it's been since you filed the claim.

    In a FMC award, you are still subject to all the same rules, including the 24 visit cap on PT/OT/Chiro.

    The benefits in a stipulation or Finding w/Award & Order, if if you are still within the 5 yr SOL to petition to re-open the org claim, you can, and be eligible for new and further disability... a new PD/WPI rating.

    The problem with FMC is that it covers the ''normal progression of the injury/illness''....if you return to work and reinjure, aggreviate, exacerbate the prior injury... that would/could be a new injury/claim.

    A judge would not likely spell out any future medical included in a F&A/O, but rather include a statement to the effect of ''future medical per the PTP/AME/PQME report". Basically, ''as needed, based on medical necessity''.
    how do you go about accessing it?
    Go back to your PTP. Even though you have been released from care, the doctor is still your PTP.

  3. #3
    Join Date
    Sep 2009
    Location
    CA
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    6

    Default Re: Future Medical Care

    So my question was, did you get any help from having future medical care? It sounds like neverending hassels even after you settle.

  4. #4
    Join Date
    Jul 2008
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    ca
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    863

    Default Re: Future Medical Care

    MikeJ, I agree, it sounds never ending. I think when people say they have lifetime medical, it means a lifetime of BS from WC.

    If the IC denys like they do when the claim is "open", I woudnt want to guess as to how they treat you when its closed. I would be interested to hear from people whom have "settled" with medical, and actually dont have to fight for every pill or procedure.
    Never doubt that a small group of thoughtful, committed citizens can change the world...indeed...its the only thing that ever has - Author Margaret Mead

  5. #5
    Join Date
    Feb 2007
    Location
    Calif
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    Default Re: Future Medical Care

    So my question was, did you get any help from having future medical care?
    I'm not clear as to what you mean by 'getting help'...?
    There is no difference in the medical treatment you receive, or how you access that treatment under a FMC award, or as when the claim was 'open'.

    WC is a system. The ER is the insured party. The IW is the receipient of the benefits due to the injury/illness they are claiming the ER is liable for. The IW is not the insured party, and the medical provided is not ''health insurance/coverage''. So, future medical is not 'open' any more than prior to a FMC award/agreement.

    Your PTP is still charged with the same process as when you were actively treating your injury. Same ACOEM/MTUS guidelines, same UR process. The ER/IC is entitled to control the cost of treatment through the use of the system.

    I've have a Stipulated agreement/settlement in place since 2002. I continue to see my PTP on a regular basis. If the need is medications/re-fills, it's about every 4 months... if there are other needs, it's once per month. If there are treatment needs outside the maintaince level, a PR-2 must be submitted to UR. In fact, every 6 months, or depending on the meds', every 12 months, the medications must go to UR to determine the continuing medical necessity.

    FMC covers treatment to the ''natural progression of your injury/illness''. While that treatment is available 'for life'... the IW/PTP is still charged with proving the medical necessity/need for the treatment/benefits requested.

    Given those perameters... if you were to trip/fall, or are injured in a MVA... or are to aggreviate/exacerbate your injured body part/s outside that ''natural progression'', those FMC benefits could be denied.

    BTW... you should also know the IC has the right to monitor your condition, even by use of a PI, and file for a reduction of your PD, the same as you have the right to petition to re-open your claim within 5 years of your org DOI for new and further disability. Until you fully close your claim by C&R... it's ''open''.

  6. #6
    Join Date
    Jun 2009
    Posts
    216

    Default Re: Future Medical Care

    I have a story.

    I just had a pretty major sugery two days ago under an award for FMC from 8 years ago Everything was authorized in a timely manner. MRI .Meds. Surgery.Without FMC Iwould have been completely screwed.Great MPN doctor/ surgeon. The Ic I am sure spent a bundle to help me. No complaints here. I am receiving top notch state of the art care for my injury. I am greatful. The whole process took three months so far. I did not have to fight for anything
    Last edited by Interceptor; 10-03-2009 at 08:38 AM.

  7. #7
    Join Date
    Jul 2008
    Location
    ca
    Posts
    863

    Default Re: Future Medical Care

    Thanks Inceptor!!! Good for you, I hope you are recoveing good. It is nice to hear that you didnt have to fight tooth and nail.

    Did they treat you good throughout your whole claim? If so, good for you, Iam glad an IC/CA stepped up to the plate and did the right thing..


    Take care
    Never doubt that a small group of thoughtful, committed citizens can change the world...indeed...its the only thing that ever has - Author Margaret Mead

  8. #8
    Join Date
    Feb 2007
    Location
    Calif
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    Default Re: Future Medical Care

    That is the way it should be interceptor...and generally is. When there is medical evidence, supported with valid reasoning by your PTP in a request for treatment, then the request will pass UR.
    That's not to say the ER/IC is not entitled to a second opinion, or further determination to medical necessity.
    Unfortunately there are very few IW's who take the time to post on a message board the many claims that do move successfully through the system and benefits are provided timely and appropriately.

    The system sucks..we all agree to that... but there are lots of claims that resolve, even with significant injury, that we never hear about.

  9. #9
    Join Date
    Dec 2007
    Posts
    91

    Default Re: Future Medical Care

    I would file for SSDI and have the ER/IC reimburse SSDI for medical treatment with the medical set aside

  10. #10
    Join Date
    Feb 2007
    Location
    Calif
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    Default Re: Future Medical Care

    I would file for SSDI and have the ER/IC reimburse SSDI for medical treatment with the medical set aside
    1) Application/award of benefits of SSDI can take quite a long time.

    2) SSDI does not pay for Medical treatment.

    3) Once your DOO/Date Of Onset is determined, you have a 5 month waiting period for benefits to begin...that's your DOE/Date Of Entitlement.

    4) There is a 24 month waiting period after your DOE for Medicare eligibility.
    Medicare pays for treatment to non-industrial medical needs.
    It's not as simple as just having treatment and billing Medicare. IF Medicare makes conditional/advances payments, those must be reimbursed prior to any settlement.

    5) If there is a need for WCMSA, and there isn't always a need...the MSA would not be reimbursed for past treatment to your injury. WCMSA is for treatment going forward.

    I numbered these issues here only to show the time frames involved, and what you are up against in SSDI/Medicare paying for treatment to your work related injury.

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