California Worker's Compensation - Help For Injured California Workers

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  1. #1
    Join Date
    Apr 2010
    Posts
    3

    Default Cost of Spinal Surgery

    VERY new here, be kind haha. I am about to get an offer to settle my WC claim C&R. I have bulging lumbar discs with no surgery so far. The QME said I "may" need spine surgery in the future. The CE said she would be offering me a portion of the cost of spine surgery in the Future Medical portion of the settlement offer. I realize this may be about 25% percent of the cost of spine surgery. Here is the big question: What does the CE use as the "cost" of spine surgery in California? I found the Workers Comp Official Medical Fee Schedule, but it is too complex to even find the spine section. Can anyone give me a ballpark of the price the CE is going to base her settlement offer on? I want to be prepared to either accept her offer or demand something different. (p.s. if you need the info, I have an impairment rating of 10%, I'm 46 years old and female, but the QME apportioned 50% to degenerative disc disease. But I'm just asking where they get the figure for the surgery cost). Thank you.
    Last edited by ssharry; 04-13-2010 at 01:28 PM. Reason: additional data

  2. #2
    Join Date
    Jul 2008
    Location
    California
    Posts
    1,898

    Default Re: Cost of Spinal Surgery

    Hi ssharry,

    I do not think anyone on this site that can tell you the cost of the spinal surgery you may need in the future. There are many different types of spinal surgeries, and your condition may or may nopt worsen over time. There are also costs of physical therapy, medications, and hospital costs. Some people who have spinal surgery have to undergo additional surgeries if there are complications. One member on this site told me his surgery costs for his second spinal surgery was over $300,000. due to complications and additional stay in the ICU of the hospital.

    If you may need spinal surgery in the future, I would not sign a C&R. This is my own opinion. Once you sign that, all costs for your injury in the future will be your responsibility. You will not be able to use a private insurance or Medicare.

    If you do not have an attorney, I recommend consulting with one....or an Information and assistance officer at your local WCAB.

    Whatever you decide, I wish you well.

  3. #3
    Join Date
    Apr 2010
    Posts
    11

    Default Re: Cost of Spinal Surgery

    Interesting to see these posts. I, too, am faced with the same dilemma. It seems as if attorneys say that private insurance would cover the costs as long as one had a group policy, since pre existing conditions would not be a factor. I am /was skeptical as no attorney is willing to put this in writing, so how can it be true? Very scary , indeed. I also read in these posts that industrial injuries are not typically considered pre existing conditions, thus they can be excluded from coverage.The money is tempting, but if there are no guarantees of future coverage, how can anyone go that route? Is the track to getting surgeries approved after the settlement (5year threshold) onerous?

    Thanks to all for posting such wonderful detail.

  4. #4
    Join Date
    May 2009
    Posts
    158

    Default Re: Cost of Spinal Surgery

    WELCOME.....

    C&R may not be appropriate in some cases especially in possible future
    spine surgery scenarios..

    please read through some of the posts here if you have the time and are
    able to do so...
    we have some truly great people here with great information...
    take care..pv

  5. #5
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: Cost of Spinal Surgery

    WC is about liability of your ER, not settlements you might receive for suffering the injury.
    No PD/WPI, no indemnity would be due. No future medical needs, no FMC money would be paid.

    Your GHP doesn't pay for industrial injury/illness because the ER is liable for those costs as part of the claim. Not the IW. Even after you are MMI and released to return to work, the ER continues to carry that liability as long as treatment is found medically necessary.

    IF you are paid a lump sum to close the claim, you are agreeing to release the ER/IC from all future claims to your injury. As such, you are also agreeing to accept liability for any/all FMC you may require, and use the money you receive in the lump sum. You will NOT see money for a surgery you may or may not seek regardless of what the PQME/AME or your PTP say in a final report. Carriers know IW"s generally seek much less treatment for their injuries once that lump sum is paid.

    And, as all settlements are now reported to CMS/Medicare, you will be required to prove you have spent all of the FMC money, including reasonable interest, on treatment to your injured body part before Medicare will pay for treatment. If the allocations are not done properly, the ENTIRE amount of the C&R could be declared by CMS to be for future medical reimbursement.

    Bottom line, if you require FMC you should not take a C&R. Lump sum buyouts are always in the best interests of the ER/IC, seldom those of the IW where FMC is anticipated.

    For any surgery you have to consider the Dr/surgeon/team costs, hospital stay, medications, probable PT/OT, wage loss/TTD while you treat/recover. And you cannot use a combination of your FMC money and GHP/private pay health coverage.
    I also read in these posts that industrial injuries are not typically considered pre existing conditions, thus they can be excluded from coverage
    What we may think of and use in everyday language as "pre exsisting condition" and the health care reforms, and how the laws/language define pre exsisting are often much different applications.

    While a industrial injury/illness may well be considered a pre exsisting condition once you treat/recover and return to work, the ER/IC is still liable, the claim doesn't close, until you cash out. If you are working and aggreviate that prior injury, it would be a new injury/claim. ER is still liable.
    WC is not about ''health coverage'', as above, medical treatment is but one of the benefits the ER is liable for.

  6. #6
    Join Date
    Apr 2010
    Posts
    3

    Default Re: Cost of Spinal Surgery

    It's too bad no one was able to answer my question. I have read extensively on this forum, and whenever this question is asked the answer is "get an attorney" or "don't C&R the FM" and "you'll be denied medicare!!" etc etc. I can take that to heart while still wanting to know at least a ballpark figure of how much either a fusion or laminectomy costs. Has anyone had one? Has anyone C&R'd and gotten an amount for FM for laminectomy or fusion? Does anyone have at least a ballpark amount for a non-complicated surgery, so that if I choose to C&R this I know how much to ask for?

  7. #7
    Join Date
    May 2009
    Posts
    158

    Default Re: Cost of Spinal Surgery

    SSHARRY..
    i believe your question did get answered here,perhaps you missed it?
    even by knowing the exact cost of this procedure it MAY have little value as
    a tool in negotiating a C&R...your CE already knows what she is willing to
    offer you now(most likely) and as you stated earlier she would offer you a
    portion ? or did the CE specifically state 25%?..

    i would also like you to know that an attorney CAN negotiate a C&R far
    better than an IW alone against an insurance co.and their attorneys....

    also you have read thru some of the posts here and found a lot of
    "get an attorney" "dont C&R your FM" and so on...
    do you suppose these bits of advice could be the general consensus here??

    here at this board are years and years of experience in w/comp..and i
    believe the good people here ARE a lot more concerned for your WELL BEING
    than your CE................................................ you can BANK that...

    i hope that you get all you are expecting and your future be bright.....
    take care.......pv

  8. #8
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: Cost of Spinal Surgery

    There would be a number of factors involved in estimating the potential value of FMC that includes a surgery. TTD for the time to treat/recover, PT, OT, hospital (days now in acute care, ie 3 for your surgery might be around $1800/day) The surgeon, assist, surgical team, anesthesiologist, hosp charges for OR...''clean up'' of my OR was 6K, that did not include the actual "rental" for the surgery) There would be the cost of medications, dressing, portable X-rays. The costs go on and on.... and, the carrier is paying per the OMFS/fee schedule...which you DON"T have the benefit of. The hospital will bill you usual and customary.

    On top of not being able to use contracted fees...or the WC OMFS... you would not receive the full amount of an SWAG/Scientific Wild Ass Guess and any money they come up with would be paid in todays dollars... a significant discount. And, as I think I pointed out, carriers are loathe to fork out money for a surgery you may or may not seek post settlement.

    The longer you wait, the less that money will cover...inflation, and the cost of medical treatment in general will see to that. So, your out of pocket cost would be significant.
    if I choose to C&R this I know how much to ask for?
    One, it's not your 'choice', it would be up to the CA/carrier to make you an offer, IF they were interested in cashing you out.
    Two, you can't force a lump sum payment....nor could a judge order one.

    About 10 years ago, when a cervical laminectomy was the "procedure of the day" a friend of mine (actually about 4 in all) had a single level procedure, anterior, in one day, out the next, that was paid at about 35K per the OMFS. inclusive.
    My last surgery was billed a usual and customary at about 325K, carrier paid after bill review...80K. That did not include the 35K to the surgeon. Or attending and team...

    So, even IF your FMC was valued at 35K, they won't pay it, and IF there was a negotiated amount, say 15K, paid full, you'd have that 20K out of pocket when you sought the surgery... and from what you say... you will eventually.
    "Don't C&R the FMC" is not bad or frivolous advice from the members here.

    Call the hospital, ask the ''average'' billing for 3 to 5 days... OR charges for 4 hours....talk to your Dr/surgeon, get the "average" charges for surgeon/assist, anesth.

  9. #9
    Join Date
    Apr 2010
    Posts
    3

    Default Re: Cost of Spinal Surgery

    Thank you, BVia, that is what I was looking for.

  10. #10
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: Cost of Spinal Surgery

    You're welcome. But, IF you are contemplating a surgery, you should not close out the medical coverage in the claim.
    And, if you return to work, aggreviate the injury and file a new claim, you could be required to spend that FMC money on medical before the next carrier would kick in the payments/benefits. You can't be paid twice for the same loss....

    FMC is not money for disability/impairment you suffer due to the injury... that's what the indemnity is for.
    No need for further treatment...no money for FMC.

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