20 Year Anniversary Coming Up

[twomoons]

bvia, i recieved 20,000 from the ic ,as they went by thier qme reccomendation.my aa did not get any money from that amount
in a pm i told you where the the other 50,000 went.
i guess i was confused on the c&r lump sum i thought the lump sum included the future medical set aside amount.
she keeps saying the only cash value left in my case is the future medical.
and that she wants to do a c&r.bvia, this case is really messed upmedicare has gone after the ic to get paid for the 4 previous neck and back operations.
my ptp will not deal with the state of ca. period. i have called 6 pain clinics,and they will not deal with wc in cal.period.i have a great ptp for all my other medical needs,and my family ,and i do not want to lose him over a wc system like the cal. wc. system.
and you are right bvia, and i hope every IW read what you said,getting a judges ordr for medical care does not stop the UR process. and i have not met a dr. who will deal with the cal wc ur process. i have been turned down several times because of the ur process.
the IC has said i have very little disability, but they still paid a bunch of money,before being ordered to, as far as the pd goes. it is confusing to say the least

[twomoons]

bvia, you said on a c&r, the fee is based on the total of settlement. what is ued in total settlemnt.
the the future medical figure??
the pd rating??
the loss of future arnings??
thanks for reply

[BvIA]

Whatever there is to be settled by the C&R.

[twomoons]

bvia,
ok, so do all the issues have a monetary value, the pd, the loss of future earnings, the future medical,etc,and does the AA get a fee off od that total amount.
i though you said in a previous post that wcmsa will not give any money to a aa out of future money that put away for future medical??

[BvIA]

You said your PD indemnity has been paid... your AA got a fee from that in the Stipulations. (Don't kid yourself, the AA got a fee already)

i though you said in a previous post that wcmsa will not give any money to a aa out of future money that put away for future medical??

No...I said CMS/Medicare will not allow WCMSA money to be used for AA fees.
IF there is a C&R for the FMC in your claim, and there is allocation to a WCMSA, and money for indemnity OR non-Medicare FMC, there can be additional AA fees paid. You should NOT C&R a FMC award for WCMSA money only.

ok, so do all the issues have a monetary value, the pd, the loss of future earnings, the future medical,etc,and does the AA get a fee off od that total amount.

PD/WPI ratings contain consideration for future loss of earning capacity. ALL items in a comp claim have a dollar value at some point. That is what settlements are based on. In a C&R, any settlement the AA negotiates for the IW there is a fee due. That is the reason you have an AA...to represent you and your best interests in a claim.

[twomoons]

bvia,
my aa told me this morning she wanted to sign off on case,and let some one else handle it. her exact words. she said she would file a lien, and just see what happens. i am not making this up bvia. she has said her office has not recieved a dime in any fee's. there is no settlement yet. bvia, i am not kidding, this whole case is so messed up. and i am trying to explain things as simeple as i can.
she wanted to quit, unless i sent the last 4 years of self procured medical records by tuesday,. bvia i have to keep problems as simple as i can, so please bear with me if you seem like your repeating.
the IC qme said my pd rating was low. they have paid about 25,000
the AA qme said my disability was high,and i would need a lot of future medical care.
the IC qme said in there report 3 years ago i did not need anymore medical treatment as i was p&s.
so i was cut off from all medical treament.
so i used medicare and my wifes ins to get the medical treatment done.
my pcp has me on a high level of several pain meds, and muscle meds.
my physch doctor has me on some ptsd meds.
i have paid out of pocket for all these meds for 4 years.
my ptp ,and several spine specialists have all recomended nerve block injections, pt, and pain meds. so there are several docs, besides the ptp who have the same diagnosis.
bvia, i asked my AA this morning this question. the IC cuts off all treatment based on thier qme report. i know we dont have to discuss why the ic will always give a low pd rating. thats just normal. and my aa qme gives me a high rating. thats a given. and i thought there was a person who looked at both qme reports,and gave thier rating to the wc judge.
i guess the IC attorney is saying i dont need further medical treatment because i have not seen any treating doctors for 4 years.
but how can she know who or what i have done if they dont pay for the treating docs, and therefore have no record of my medical history
the IC is saying we wont pay for any thing, and then when they dont get any records, say "see" i told you, he does not need any medical care.
i have had half a dozen steroid pain blocks, several. mri procedurs to try and find out whats wrong.
on a high dose of pain meds, i could go on and on.

bvia, how can the IC say there is hardly anything wrong with me, but still almost pay 100,00 in pd awards. its all so confusing to me.

the IC qme did agree with my AA qme i would need further pain management.
if both qme docs say i will need ongoing lifetime medical care, why is it so important that i have to give all the medical history from the last 4 years.

[BvIA]

How do you calculate a 'low rating' with 100K in PD awards. ?

As you have AQME, and DQME, and say there has been no actual rating, or anyone has actually come up with something to base PD on... how are you being paid PD ?

If your AA was doing something to move this forward, an AME would be used to settle these disputes.

You obviously have a complicated claim... your move out of state did not help matters. Because your doctors are not sending medical progress reports to the IC, or cooperating with the Calif rules on WC... you are being denied benefits. Plain and simple. Medicare IS going to get their money back. The don't pay for industrial injury. Your wifes GHP is likely going to lien on your claim...and they too will be reimbursed if they can get that far.

You say you don't have a rating...the PD is paid out, and the AA claims no fees have been paid. A judge must award the fee...and there is obviously money there because the DA/CA knows you have an AA, they won;t pay out all the PD associated with the estimated PD rating they have calculated.

If you are not willing to provide the medical records your AA is requesting which appear to be in your best interests... she is trying to get your out of pocket costs paid back to you... I can't blame her for requesting to be released from representing you. You are likely to be on your own.

the IC qme did agree with my AA qme i would need further pain management.
if both qme docs say i will need ongoing lifetime medical care, why is it so important that i have to give all the medical history from the last 4 years.

So you can get your money back. WHY are you resisting providing YOUR AA with the medical records. ?

Just because a doctor says you may need future medical care, does NOT mean you automatically going to get it. ALL treatment...ALL, is subject to MTUS/ACOEM treatment guidelines...and the UR process. And Calif law will prevail in those determinations. The carrier does NOT have to pay for treatment you don't follow the rules in securing prior authorization for.
If you follow those rules, self procured treatment can be reimbursed, and the medical records of your out of state doctors can be admissable. YOU have to cooperate with your AA... she is working for you.

the IC qme said my pd rating was low. they have paid about 25,000

the IC qme said my pd rating was low. they have paid about 25,000

So... which is it.? 25K or 100K ? Why would they pay 100K on a 'low rating'...?

Im not sure what you are looking for here....? There is a lot of discussion in 45+ posts... and as of yet, I don't get it.
What do you want your AA to do ?
You moved out of state, you have doctors who won't cooperate with Calif WC rules... you are treating under your wifes GHP ins, and Medicare where you should not be billing for treatment. And now you don't want to provide the information your AA is asking for so she can move this forward for you and in your best interests... .

Do you WANT to handle this on your own...?
Or do you really not understand what is happening? I have to admit, I dont, not based on the info you are proividing.
I know you'll call me an ass again... but I'm not understanding this any better than you are, obviously.

[twomoons]

bvia,
i sure wont call you a @@@. i should not have done that in the first place.
bvia, i really am trying to keep this simple ,so i can get advice.
i have recieved around 25,000 in pd from the ic.
based on thier qme dr report..that is what the ic letter said.
my aa has told me several times thier office has not got a dime in fees.
i did send 4 years of treatment documentaion last week to my aa.
when the IC stopped paying for my medical treatment 4 years ago, my AA told me to get medical treatment any way i could, even to have mdicare pay for it, and the aa would file the papers for medicare to get reimbursed at final settlement time.
my aa thinks my pd rating will be around 50%, based on the aa and ic qme reports.
i told you in a PM where about 45,000 of a final settlemnt will be going,in a lien filed against any award.

bvia, 45,000 in a lien,plus 25.000 in pd payments paid is 70,000.
i was making about 5000 a month at injury time.
as you can see, my aa does not think their office will get any money.
so they have basically moved on.in a phone call last week the aa even said she was going to drop case, file a lien against any future settlement and just sit back and watch what the this case unfold. i could not believe that. can a aa drop a case for any reason??
bvia, i have talked to ic adjuster, and they have told me the ic attorney is going to file some kind of legal action because my aa has not done anything in 2 years, as far as cooperating with reports, answering any qustions as far as getting this case to a final settlement.
i agree, i can be awarded 100 percent future medical care, but, where i live, there is not one dr that wants to deal with the cal wc system,or the ur process.
but my aa told me to get medical treatment any way i could and the aa office would handle any problems that came self procurred treatment

[twomoons]

BVIA, I TALKED TO MY aa YESTERDAY. I MAILED 4 YEARS OF SELF PROCURRED TREATMENT DOCUMENTATION. the I C attorney has used the arguement i must be ok, becausre the IC had not got any reports. my reply was why send reports if they will not pay for treatment.
anyway, as you know my case is pre 20005.
my AA had told me i would at least get medical treatment based on pre 2005 guidlines. but she said yesterday that arnold had even gotten into changing the rules and guidlines and amounts of future medical awards.Is that possible.
bvia , most docs in this state will not deal with the cal WC UR process. and even if i could find a doc in cal., they would still have to go through the ur process.
it really looks like after all these years, and the ratings i have, there will be nothing left at my age of 58.
i guess i should be happy i have SS,and just say the hell with the IC and state of ca. wc system.
i guess i should be lucky i got hurt and just about died when i did.
it is just really really sad

[BvIA]

There have been no changes to future medical awards. You are still subject to prior authorization to all medical treatment, and the Dr has to cite ACOEM/MTUS treatment guidelines to support the request.

The ACOEM guides are used all over the US. it's not selective to which state. All industrial injury Dr have a copy of those treatment guides.

If you don't have a Dr willing to participate, what can I say.?\

You are Medicare eligible, as such you must have a WCMSA proposal sumbitted to CMS/Medicare for review on any FMC settlement. If the WC carrier doesn't want to participate in that program... nothing you can do to force it.

If you can't find a Dr to treat to the Calif mandate.. find a new Dr, or get your AA to insist they bring you back to Calif for treatment. Regardless of the location, the ER/IC is required to provide adequated medical treatment to your injury. You are not mandated to find your own doctor and tell them who you are treating with.

Moving out of state creates a multitude of problems at times...I've done it, I know what your're up against.

The perfect way to get something moving is have your DR submit a request for treatment, UR denies, you appeal by requsting in PQME/AME,,, they have to bring you back to Calif for that evaluation. Do that several times, you'll get someones attention to settle out the claim