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  1. #11
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,021

    Default Re: Claim"Conditionally Denied"

    My PQme on 8/11/10 was a 4060(compensability exam) at the CA's request.(still waiting for Medical report). With the specialty of CA's choice (Orthopaedic Surgery)- other than spine or hand. 3 letter Code MOS.
    A 4062 exam is NOT a medical/legal evaluation..PQME or AME... just a exam at the request of the CA... has no ''legal'' bearing on resolving any disputed medical issue.
    Claim denied 8/25/10. Do I need a 4062 PQME to dispute the denial now? or wait for 4060 PQME report.
    There is NO SUCH thing as a 4060 PQME... a PQME is selected from a list of QME's provided by the DWC medical unit, YOU must be given the first opportunity to request a list, and select the Dr to perform the evaluation.
    Will the 4060 serve me as Labor Code 4062 in this case?
    NO..basically because you had no involvement in this process. The labor code is very clear, disputed medical issues ''shall'' be resolved by 4062 process, 'only'.
    I have not initiaded the 4062 process.. I've only done the 4060.
    CA is trying to pull a fast one here. The 4060 exam is NOT the correct process in determining compensability of the claim. You MUST use PQME if the CA is going to deny, regardless of the reason... "conditionally denied" is "BS".

  2. #12
    Join Date
    Aug 2010
    Posts
    70

    Default Re: Claim"Conditionally Denied"

    There is NO SUCH thing as a 4060 PQME... a PQME is selected from a list of QME's provided by the DWC medical unit, YOU must be given the first opportunity to request a list, and select the Dr to perform the evaluation.

    The form used was "REQUEST FOR QME PANEL UNDER LABOR CODE 4062.1(unrepresented)provided by the DWC medical unit.

    The reason the QME panel was requested by IC/EMP 4060 (compens exam)
    I did select QME from a panel of 3, set the appointment and go to the appointment. I'll look up Labor Code 4062.1

    So I did have a 4062 PQME....ok making sense now. Thanks BVIA for your patients and input.

    Have A Great Day!

  3. #13
    Join Date
    Aug 2010
    Posts
    70

    Default Re: Claim"Conditionally Denied"

    Picked this up on another forum :

    4060 is not reserved for denied claims. It is reserved for cases that are not accepted in order to determine compensability. Therefore you do not have to deny a case before obtaining an exam under LC 4060 but you may very well need the evaluation before you can deny the claim or else there is no basis to deny the case.
    It would seem that IC's/CA's utilize the 4060 exam to justify denials of claims. So, it would seem that if the report comes back favorable to the IW, the WC claim would be considered compensable? If the CA can use it to justify denials, one would assume the IW can use it to his/her advantage.(if favorable)

    Hence> "Conditional Denial" ?
    Last edited by I.W; 09-02-2010 at 11:37 AM. Reason: add

  4. #14
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,021

    Default Re: Claim"Conditionally Denied"

    4060 does not carry legal status. It is a Dr opinion, and yes, they can use, they can use any Dr report to contest a claim.
    That does not mean it is a valid, legal denial.

    4062 and 4062.1 are completely different animals. The PQME is the ONE that counts. They either PAY benefits due, OR, file the DOR and Application for Adjudication of the claim.

    4062.1 PQME counts
    4060 doesn't. For medical/legal resolution.

  5. #15
    Join Date
    Aug 2010
    Posts
    70

    Default Re: Claim"Conditionally Denied"

    100% clear. Thank You Bvia. I'll post updates as they occur.

  6. #16
    Join Date
    Aug 2010
    Posts
    70

    Default Re: Claim"Conditionally Denied"

    Update
    After several Consultations, I'm rep'd. and relieved that the attorney can/will deal with the CA's BS from here forward. All the AA's say the surgeon I elected to be my PTP in the MPN has a reputation for being Fair and NOT against the IW. Hopefully,(on a lien basis) I'll be able to continue treatment there. When I called the CA to change my PTP ( a few days before I received the Denial notice) The CA asked " why this particular Dr.?" For almost 10 minutes she tried and said any/everything to discourage me from changing PTP. I finally asked her " Am I within my rights to change PTP in the MPN?" she gasped and said YES with an attitude. She was already pissed at me because I Email her supervisor everytime she ignores my phone calls.
    My attorney says I've done good on my own so far but "we're just getting started" and I owe that to this forum and those who offer their experiences, knowledge and explanations with answers to those questions that we (IW's) put out there.

    In my case and from Post in the forums... I've learned that IC's/CA's will lie, deny, delay and do whatever it takes to discourage IW's from pursuing benifits...wishing we'd just give up and go away! IMHO.

    I'll updated progress on this thread...Later

  7. #17
    Join Date
    Aug 2010
    Posts
    70

    Default Re: Claim"Conditionally Denied"

    Hi all,
    well almost 3 weeks have passed since I received the denial and told not to keep my appointments in the MPN ( over the phone). I know phone conversations mean nada when it comes to CA's word against mine.The Denial is documented.
    Last night, the PTP called me to confirm my appointment with the Ortho-surgeon specialist. Should I go? and why hasn't the IC/CA canceled/Informed them of the denial? I haven't missed, canceled or rescheduled a single appointment since the beggining of my claim and wouldn't put it past the CA to use it against me. I won't be able to talk to my attorney before the appointment time. Maybe I should just reschedule, Talk to AA and go from there..... Just curious, if I did go, would I get the bill for this particular visit for treatment?

    I also switched to a different PTP in the MPN before the denial. The appointment for this morning is with the first treating physician.
    Thanks
    Last edited by I.W; 09-10-2010 at 07:12 AM.

  8. #18
    Join Date
    Aug 2010
    Posts
    70

    Default Re: Claim"Conditionally Denied"

    Thanks Clark,
    I called and rescheduled. That way nobody can suggest a ''Denial of care on my part'' . Better safe than sorry ...........I suppose. I wanted to go cause this sciatica is kicking my A$$ today!

    Have a good one

  9. #19
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,021

    Default Re: Claim"Conditionally Denied"

    Claims get confusing at times... and sometimes IWs cause confusion, generally due to ignorance of the system...(notice, I did not say 'stupidity"....)

    When you are treating with a PTP in the MPN, and there is a denial to the claim, or even any disputed medical issue, you canNOT change PTP until the dispute has been resolved. Based on the info you provide here... you have NOT changed PTP, or should not have changed PTP/Dr... MPN or otherwise, until there has been resolution to the denial of your claim.
    As the claim is denied, a Dr who provides treatment will bill you/IW... the ER/IC is not liable for the cost of treatment in a denied claim. Until/Unless a judge finds otherwise, and orders the claim compensable.
    Just curious, if I did go, would I get the bill for this particular visit for treatment?
    Yes, and rightfully so. [QUOTE]I called and Reread this post... any Dr you see for treatment to this injury/claim is not going to be paid UNTIL a judge orders the claim compensable. Be ready to pay out of your pocket.

  10. #20
    Join Date
    Aug 2010
    Posts
    70

    Default Re: Claim"Conditionally Denied"

    Hello Bvia,
    When I elected to change PTP the claim was still active.(in delay pending the 90 day).The IC/CA did allow my first choice right to switch PTP. At one of my consultations I was advised to get away from my current FTP/PTP ASAP.(knowing I had A delayed claim and pending PQME report) So I did.

    All the AA's say the Dr. I elected to be my PTP in the MPN has a reputation for being Fair and NOT against the IW. Hopefully,(on a lien basis) I'll be able to continue treatment there.


    I was looking for PTP in the MPN that was closer to home. I've been doing 108 miles round trip Since the DWC(1) was filed.(over 3 months ago) with over 1500 miles logged. The PTP I selected came highly recommended at all the AA consultations.

    I have not been to any doctors in the MPN since the claim was denied.(18 days ago).. Any treatment I receive now will be through my own health insurance provider.(and billed accordingly) I hope. My personal physician has made a point to treat my "chronic back pain" issues as opposed to my work related injury.

    Until my AA can get a Dr. in the MPN to continue care, I will continue to see my Family doctor's. We are still waiting for the PQME's medical report to determine what will happen next.

    IMO..If the IC's would quit dragging their feet and notify the PTP's of the Denials and cancel future treatments/appointments the clinics/PTp's wouldn't be calling to confirm appointments that shouldn't exist, eliminating confusion with the IW's and PTP. It shouldn't be the I.W's responsability to tell the PTP they might not get paid because of denied claims. I had to tell the them on the phone my claim was denied. But rescheduled anyway..just in case.
    Thanks Bvia.
    Hope my situation is ok ....check back later..have a good one!
    Last edited by I.W; 09-10-2010 at 11:48 AM.

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