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  1. #1
    Join Date
    May 2010
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    6

    Default Compromise and Release Documents Needed to Be Signed Before Medicare Will Review

    Compromise and Release documents needed to be signed before Medicare will review the proposed settlement.

    After getting a medical set aside analysis offer from the defense, which buy the way seems bias just for the fact that it was done by the defense and not a unbiased party. I agreed to submit it to Medicare in the hopes that they would see it for what it is , a low ball estimate designed to save the employer money and reject it .
    Now my lawyer says that there are additional papers that need to be sighed before Medicare will review the proposed settlement. ( In other words if Medicare doesn't see that there is a agreement in principal they will not bother to review the Medicare Set -Aside analysis.
    After looking at these papers I feel like they are really meant to protect the employer and not me and i also find it hard to find that medicare would require my signing of these. Such as a Voluntary Resignation From Employment form.
    By signing this I would be.
    1) Releasing any claim to back pay. ( they owe me vacation pay )
    2)Waiving my 48 hour provision to rescind any agreement ,including the corresponding Compromise and Release.

    There is more but this is a good place to start. Is there a phone number to contact Medicare and see if these things are needed
    Last edited by dog; 05-11-2010 at 10:50 AM.

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

    Default Re: Compromise and Release Documents Needed to Be Signed Before Medicare Will Review

    Compromise and Release documents needed to be signed before Medicare will review the proposed settlement.
    A CMS/Medicare review of WCMSA proposal is not dependent upon signing a C&R agreement....the proposal should be sent to CMS for review before the final negotiations are completed and settlement agreed to. Someone is providing misleading information to you or your AA/atty.

    It's not unusual for the carrier to provide a MSA proposal... it's just a SWAG/Scientific Wild Ass Guess to the potential value of your FMC/Future Medical Care ....there are triggers that require a proposal be developed, and/or submitted to CMS, there is no law that requires the actual review/approval.

    The settlement would NOT be complete or accepted by CMS until the actual documents are submitted after they are reviewed for adequacy and approved by a WCAB judge.

    You should be requested to sign a release of information form so the carrier/MSA vendor can get your SSA/Medicare status. They need to determine if you are Medicare eligible, and if there have been any conditional payments made for your treatment by Medicare. Those must be reimbursed before the settlement can be finalized.
    By signing this I would be.
    1) Releasing any claim to back pay. ( they owe me vacation pay )
    2)Waiving my 48 hour provision to rescind any agreement ,including the corresponding Compromise and Release.
    Ther vacation pay is not under the juridsiction of the WCAB.
    Never seen any provisions for a 48 hour waiting period. Once you sign the C&R agreement, even at the board/MSC, those documents can be 'walked through' for a judge to sign off on and the settlement is complete. That day, then and there.

    I agreed to submit it to Medicare in the hopes that they would see it for what it is , a low ball estimate designed to save the employer money and reject it .
    Once the MSA is submitted to CMS for review, if they actually review the documents, they will determine if there are adequate provisions/monies to be 'setaside' to protect Medicare interests. If not, they will change the figures and tell you how much is required.
    The settlement documents in the allocations for FMC, should contain money for funding the WCMSA, and non Medicare money. You can only use the MSA money for what Medicare would normally be responsible for, when that money is exhausted and Medicare begins to pay for treatment to your injury, you will incur out of pocket costs.
    There are also limitations to what you can pay for prior to the MSA money being gone...ie Medicare limits PT and Chiro treatments... you pay with your own money, that would be the non/MSA money in the settlement.

    There are a lot of threads/posts here regarding Medicare/MSA and settlements, you can begin by reading some of the bulletins here http://www.jjcelderlaw.com/SettlementProcessMSABull.htm regarding the settlement process and Medicare involvement.

  3. #3
    Join Date
    May 2010
    Posts
    6

    Default Re: Compromise and Release Documents Needed to Be Signed Before Medicare Will Review

    Quote Quoting BvIA View Post
    A CMS/Medicare review of WCMSA proposal is not dependent upon signing a C&R agreement....the proposal should be sent to CMS for review before the final negotiations are completed and settlement agreed to. Someone is providing misleading information to you or your AA/atty.

    It's not unusual for the carrier to provide a MSA proposal... it's just a SWAG/Scientific Wild Ass Guess to the potential value of your FMC/Future Medical Care ....there are triggers that require a proposal be developed, and/or submitted to CMS, there is no law that requires the actual review/approval.

    The settlement would NOT be complete or accepted by CMS until the actual documents are submitted after they are reviewed for adequacy and approved by a WCAB judge.

    You should be requested to sign a release of information form so the carrier/MSA vendor can get your SSA/Medicare status. They need to determine if you are Medicare eligible, and if there have been any conditional payments made for your treatment by Medicare. Those must be reimbursed before the settlement can be finalized.
    Ther vacation pay is not under the juridsiction of the WCAB.
    Never seen any provisions for a 48 hour waiting period. Once you sign the C&R agreement, even at the board/MSC, those documents can be 'walked through' for a judge to sign off on and the settlement is complete. That day, then and there.

    Once the MSA is submitted to CMS for review, if they actually review the documents, they will determine if there are adequate provisions/monies to be 'setaside' to protect Medicare interests. If not, they will change the figures and tell you how much is required.
    The settlement documents in the allocations for FMC, should contain money for funding the WCMSA, and non Medicare money. You can only use the MSA money for what Medicare would normally be responsible for, when that money is exhausted and Medicare begins to pay for treatment to your injury, you will incur out of pocket costs.
    There are also limitations to what you can pay for prior to the MSA money being gone...ie Medicare limits PT and Chiro treatments... you pay with your own money, that would be the non/MSA money in the settlement.

    There are a lot of threads/posts here regarding Medicare/MSA and settlements, you can begin by reading some of the bulletins here http://www.jjcelderlaw.com/SettlementProcessMSABull.htm regarding the settlement process and Medicare involvement.
    I understand the vacation pay is not a WCAB matter .
    But by signing the Voluntary Resignation form.
    One of the agreements was that I would have no claim on back pay.
    I believe it to be something the defense wants me to sign and my lawyer's going along with it and thinking I wouldn't question it.

    The other papers I'm being asked to sign are:

    DWC-CA form 10214 ( c ) (Rev. 11/2008 ) ( pgs. 1-9 )
    State of Calif. Div. of Workers Comp. Worker's Comp. Appeals Board
    Compromise and Release

    Another thing about this that bothers me is :

    The compromise and Release is for two injuries.
    One of which the Defense is denying and this matter has not been addressed before the judge. The claim itself wasn't denied .
    The claim was in the shoulder, arm and elbow but wasn't diagnosed as being caused by bulged dics in the neck till later. The Defense doesn't want to say its a neck problem.
    My Attorney says he didn't want to argue that . He said he was concerned that if we lost on that point, the offer would go down. My view is that they are making a offer based on denying it now.

    Whats your take on this ? Thanks
    Last edited by dog; 05-11-2010 at 02:10 PM.

  4. #4
    Join Date
    Feb 2007
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    Calif
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    Default Re: Compromise and Release Documents Needed to Be Signed Before Medicare Will Review

    Actually doens't matter what the body parts are in a C&R, you are closing the claim completely. No further medical treatment would be provided.
    The final PD/WPI rating is to your whole person... not body parts.
    If there were a stipulation settlement, THEN the body parts accepted in the stips for future medical would be important.

    If you need further medical treatment, you should NOT close the medical in this claim.
    I don't remember, vacation time in Calif is vested...so even though you may not have claim to past wages, you are due the accrued vacation time... and there is a statutory time limit to pay you any accrued time whether it's vacation PTO/Sick or what ever time the law demands. You cannot voluntarily sign away your rights under the law.

  5. #5
    Join Date
    May 2010
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    6

    Default Re: Compromise and Release Documents Needed to Be Signed Before Medicare Will Review

    Future Medical coverage for two bulged disc in the neck would be more costly for them.
    Shouldn't this matter be taken up? Its in the doctors reports.
    Wouldn't this be something that Medicare will discover when they review the Medical Set-aside proposal. Maybe Medicare won't cover my neck in the future.

    The further treatment (medical ) is supposed to be covered by the Medical set aside.
    They want to pay it off.
    I would take future med. but I've been told , I wouldn't be able to go to the same doctors that i now have . That, I would have to go to the doctors in the workers comp. carriers network and everything would have to be approved by the worker comp. carrier.

  6. #6
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    Feb 2007
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    Calif
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    Default Re: Compromise and Release Documents Needed to Be Signed Before Medicare Will Review

    FMC/Future MEdical Care in an award though Stipulations or Findings w/Award from a judge cover the 'natural progression of your injury/illness". The medical is subject to prior authorization, the MTUS/ACOEM treatment guidelines and UR process, just as it is pre settlement. You can be compelled to treat with a Dr/PTP in the carriers MPN at any time. Just like now. Nothing changes post settlement in a stip or finding.

    Once you cash out the FMC, you are of course free to treat with any Dr willing to accept the fee schedule the WCMSA is based on.

    The WCMSA is "future medical" money. The only reason a WCMSA is included is because of your Medicare eligibility. MSA and non MSA money allocations are there only because CMS wants to be sure you don't spend the FMC money elsewhere and not be able to protect Medicare interests.

    Future Medical coverage for two bulged disc in the neck would be more costly for them.
    Shouldn't this matter be taken up? Its in the doctors reports.
    I guess I'm not clear on what your thought process is here...
    When the carrier projects the potential cost of medical treatment in the future, they take into consideration the past 2 or 3 years of treatment you have rec'd, what your Dr/AME/PQME etc, indicate what might be necessary down the line and come up with a proposal CMS will hopefully accept as protection of Medicare interests. Becasue there is treatment indicated in a proposal, DOESN'T mean that is what you will be compensated for. Because a Dr thinks you might need surgery sometime in the future doesn't mean they are going to pay for that up front now. In fact, they probably won't. And just because a MSA is submitted/approved doesn't mean the carrier must accept that and fund it. You won't see money for treatment you may or may not seek post settlement.

    You say you have bulging disks... those often resolve on their own over time, and never require further treatment or surgery. You won't be paid money for surgery you may not seek or need.
    Maybe Medicare won't cover my neck in the future.
    If you have a shoulder injury and it's accepted in a settlement/MSA, you can't use the MSA money for treatment to your neck. Medicare will pay for treatment to any body part that is not identified in the MSA/settlement agreement. But you will pay out of pocket costs associated with what Medicare provides.
    The further treatment (medical ) is supposed to be covered by the Medical set aside.
    They want to pay it off.
    .While the claim is open, or if you have a FMC award though a stipulation/Finding, the carrier pays for treatment.
    When you have a C&R and setaside arrangement, then YOU pay for treatment. You use the MSA money just like it were out of your pocket.
    No settlement, no setaside arrangement.
    If you have a stip/finding, there is no Medicare Setaside Arrangement... the carrier doesn't setaside money Medicare would normally pay for treatment. (?)
    They do setaside "reserves" to cover the potential exposure in a claim. Two very different issues.

  7. #7
    Join Date
    May 2010
    Posts
    6

    Default Re: Compromise and Release Documents Needed to Be Signed Before Medicare Will Review

    Quote Quoting BvIA View Post
    FMC/Future MEdical Care in an award though Stipulations or Findings w/Award from a judge cover the 'natural progression of your injury/illness". The medical is subject to prior authorization, the MTUS/ACOEM treatment guidelines and UR process, just as it is pre settlement. You can be compelled to treat with a Dr/PTP in the carriers MPN at any time. Just like now. Nothing changes post settlement in a stip or finding.

    Once you cash out the FMC, you are of course free to treat with any Dr willing to accept the fee schedule the WCMSA is based on.

    The WCMSA is "future medical" money. The only reason a WCMSA is included is because of your Medicare eligibility. MSA and non MSA money allocations are there only because CMS wants to be sure you don't spend the FMC money elsewhere and not be able to protect Medicare interests.

    I guess I'm not clear on what your thought process is here...
    When the carrier projects the potential cost of medical treatment in the future, they take into consideration the past 2 or 3 years of treatment you have rec'd, what your Dr/AME/PQME etc, indicate what might be necessary down the line and come up with a proposal CMS will hopefully accept as protection of Medicare interests. Becasue there is treatment indicated in a proposal, DOESN'T mean that is what you will be compensated for. Because a Dr thinks you might need surgery sometime in the future doesn't mean they are going to pay for that up front now. In fact, they probably won't. And just because a MSA is submitted/approved doesn't mean the carrier must accept that and fund it. You won't see money for treatment you may or may not seek post settlement.

    You say you have bulging disks... those often resolve on their own over time, and never require further treatment or surgery. You won't be paid money for surgery you may not seek or need.If you have a shoulder injury and it's accepted in a settlement/MSA, you can't use the MSA money for treatment to your neck. Medicare will pay for treatment to any body part that is not identified in the MSA/settlement agreement. But you will pay out of pocket costs associated with what Medicare provides.
    .While the claim is open, or if you have a FMC award though a stipulation/Finding, the carrier pays for treatment.
    When you have a C&R and setaside arrangement, then YOU pay for treatment. You use the MSA money just like it were out of your pocket.
    No settlement, no setaside arrangement.
    If you have a stip/finding, there is no Medicare Setaside Arrangement... the carrier doesn't setaside money Medicare would normally pay for treatment. (?)
    They do setaside "reserves" to cover the potential exposure in a claim. Two very different issues.
    I've been told that getting treatment is like pulling teeth with future medical.
    I don't know if that's a scare tactic to get me to settle or not . Is everything stipulated as to what extent of treatment will be given or is that something you have to fight for every time I need treatment?
    Can it be stipulated that i can be treated by the same doctors I currently have now ? It seems like being force to go to their doctors would be like using a doctor that they control
    Last edited by dog; 05-12-2010 at 11:39 AM. Reason: more questions

  8. #8
    Join Date
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    Calif
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    Default Re: Compromise and Release Documents Needed to Be Signed Before Medicare Will Review

    I've been told that getting treatment is like pulling teeth with future medical.
    Same process you are subject to now.
    Is everything stipulated as to what extent of treatment will be given or is that something you have to fight for every time I need treatment?
    Stipulations include the body parts the carrier accepts in the claim. Medical is NOT stipulated...see above.
    Can it be stipulated that i can be treated by the same doctors I currently have now ? It seems like being force to go to their doctors would be like using a doctor that they control
    NOT in a stipulation or finding by a judge.
    All medical treatment is subject to prior authorization, MTUS/ACOEM treatment guides, and UR process. Just like you are going though now to get treatment. Yes, you can be compelled to select a PTP in the carriers MPN.

    ONLY when you accept a C&R would you be able to control your treatment. You pay out of pocket, you go where ever you wish, and get the treatment you can afford to pay for.

    MPN, MTUS/ACOEM and UR process are there for the ER/IC to control the cost of treatment in a claim. WC is not 'health coverage'. Treatment is but one of the benefits/liabilities the ER/IC is responsible for.

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