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  1. #1
    Join Date
    Feb 2017
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    2

    Default Prescription Rule Changes

    What'nhell is going on with my Doctor telling me that two of my meds that he has prescribed for almost ten years are no longer covered by wc except for three months out of twelve, with no option for appeal or to even consider that the matter be looked at on a case by case basis, and that he now refuses to prescribe the tramadol that he has been prescribing during the same time? Tramadol is a schedule 4 drug with low potential for abuse, and is not a real hazard. I am hearing noises about that and other policy changes within the Bureau and would like to know more about what is going on. It is unacceptable that we be deprived of necessary medical treatment. CMS will not cover those drugs because they insist the conditions they treat are, and I believe rightly, a state workers' compensation issue.

    Hey Tony. Been a while. Good to see you're still holding the site together.

  2. #2
    Join Date
    Oct 1971
    Posts
    5,059

    Default Re: Prescription Rule Changes

    GregS
    Hey Tony. Been a while. Good to see you're still holding the site together.
    What's up dude, why aren't you using your old username?

    Tony
    Moderator Responses are based on my personal bias, experience and research - They do not represent the views of the admin nor may be accepted in the legal community, always consult an attorney.

  3. #3
    Join Date
    Feb 2017
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    2

    Default Re: Prescription Rule Changes

    Quote Quoting tony View Post
    GregSWhat's up dude, why aren't you using your old username?

    Tony
    Things have been pretty tough. I am frustrated with the poor medical treatment and bureaucratic games, both in wc and Medicare. I was awarded PTD in April of 2015 but still have to appeal denied treatment that has been part of my claim for years, and now this flat out denial of treatment with no opportunity for appeal. For instance, massage had become an ongoing thing, and now the most recent C9 filed for it has been denied. My attorney is in Columbus with Toledo being the office where my litigation is heard, so he has a hard time with scheduling, last time to the point that the appeal was held up almost six months because he found it necessary to file continuances. Any more I have told him that I will go to hearing myself if he cannot make the trip or find another attorney to stand in for him.

    It's been that long that I forgot the old login.

  4. #4
    Join Date
    Oct 1971
    Posts
    5,059

    Default Re: Prescription Rule Changes

    check your pm

    Tony
    Moderator Responses are based on my personal bias, experience and research - They do not represent the views of the admin nor may be accepted in the legal community, always consult an attorney.

  5. #5
    Join Date
    Oct 2006
    Posts
    381

    Default Re: Prescription Rule Changes

    Got it. Thanks.

    Looking at the archives in my profile, we had things going our way for a while. Putting heat on the Bureau and government officers was getting places. I regret that I had to bow out for a while to act as primary caregiver for my wife, who I lost a couple of years ago. Maybe I was too optimistic in thinking that the work would be carried on. It would not be the first time my optimism has been misplaced.

  6. #6
    Join Date
    Apr 2012
    Location
    Ohio
    Posts
    120

    Default Re: Prescription Rule Changes

    You need to talk this over with your attorney, not just your doctor. The doctor sometimes does not know everything from a legal standpoint that can be done. Yes, BWC is really cracking down on the medications that are approved in claims. But the statement that the meds are no long covered and there is no appeal may not be correct so definitely talk to the attorney.

    Also, CMS will cover medications or treatment that are not covered in the claim. So if you cannot get the medications through the claim you just need to prove to CMS that they are not covered in the claim (even though they are for conditions allowed in the claim). This again is where you need to talk to your attorney to get the proper documentation to send to CMS.
    Kristin A. Cool
    Ohio Workers' Compensation Attorney
    Practicing in Northeast Ohio, Central Ohio, and Mahoning Valley
    www.TheFriedmanLawFirm.com
    Workers' Compensation Blog

  7. #7
    Join Date
    Oct 2006
    Posts
    381

    Default Re: Prescription Rule Changes

    Quote Quoting Kristin Cool Esq. View Post
    You need to talk this over with your attorney, not just your doctor. The doctor sometimes does not know everything from a legal standpoint that can be done. Yes, BWC is really cracking down on the medications that are approved in claims. But the statement that the meds are no long covered and there is no appeal may not be correct so definitely talk to the attorney.

    Also, CMS will cover medications or treatment that are not covered in the claim. So if you cannot get the medications through the claim you just need to prove to CMS that they are not covered in the claim (even though they are for conditions allowed in the claim). This again is where you need to talk to your attorney to get the proper documentation to send to CMS.
    I have spoken with Jon Goodman, who had done pretty well by me. His response is, "Yeah. This sucks." We talked briefly about filing an action to seek to change these matters, and we agree that it would be too resource intensive and the outcome too questionable to pursue. Short of that, I am not confident anything can be done. Writing to Kasich would likely be a waste of time. His views are pretty hardcore regarding these kinds of matters, and he has been schmoozing with business interests and buttering their bread, which translates to "what can we do to screw claimants out of benefits?" I do not see that changing. I am no longer a resident so cannot count on him or congressional reps taking me seriously. My CSS does not respond to my vm, her supervisor bounced me to ombuds, who bounced me to OptumRx, who bounced me to Legal, who does not pick up. I'm more than a little frustrated.

    Getting the meds through CMS did work yesterday, and I had copays to cover. That cost does not fall to me when they are filled under my claim. My income is pretty limited, and any cost is a hardship. I am in a dispute with Social Security over an alleged overpayment of a little more than $40K which is about the entire wc benefit I received piecmeal over nine years, some of it before I was awarded SS and before they ruled in my favor and some piecemeal and temporary (wl, tt, &c) and for a year after I reported the PTD award to them at which point they finally got around to making adjustments to the SS benefit. They refuse to provide me any information regarding their methods, rules, or math that demonstrates an overpayment. I have brought in an attorney who can't make heads or tails out of that after he and I sat down and looked closely at my SS file at my local hearing office where it resides. While I wait for my appeal, they have taken my entire SS benefit and are applying it toward the alleged overpayment.

    My Mom told me as a child that I would eat a pound of dirt before I die. Pa pulled me aside and told me she was about half right, and that it's not a pound, but a ton, and it's not dirt, it's shit.

  8. #8
    Join Date
    Oct 1971
    Posts
    5,059

    Default Re: Prescription Rule Changes

    Greg
    an alleged overpayment of a little more than $40K
    I don't see them making overpayments for that long without catching it, there has to be an error - that's way too much for an overpayment.

    While I wait for my appeal, they have taken my entire SS benefit and are applying it toward the alleged overpayment.
    Did you file for a reconsideration when you received the notice of overpayment?
    If this is the appeal you're referring to, they should continue payments until the dispute is settled.
    If you're awaiting an appeal on the determination of reconsideration, they should afford you the opportunity to make payments "at the rate of the lesser of 10 percent or the entire monthly payment;"
    It's very unusual for them to withhold the entire payment, I've never heard of it.

    WHAT WILL WE DO IF THERE IS AN OVERPAYMENT?
    We will send you a notice explaining the overpayment and asking for a full refund within 30 days. If you are currently getting payments and you do not make a full refund, the notice will:
    propose to withhold the overpayment at the rate of the lesser of 10 percent or the entire monthly payment;

    state the month the proposed withholding will start;
    fully explain your appeal rights;
    explain how you can ask us to review and waive the overpayment, so you may not have to pay it back; and
    explain how you can appeal our decision.

    WHAT CAN YOU DO IF YOU GET AN OVERPAYMENT NOTICE?
    If you believe you were not overpaid, you may request a reconsideration.
    If you ask for an appeal within 10 days from the date you receive the notice, any payment we are currently making will continue until we make a determination.
    https://www.ssa.gov/ssi/text-overpay-ussi.htm

    Tony
    Moderator Responses are based on my personal bias, experience and research - They do not represent the views of the admin nor may be accepted in the legal community, always consult an attorney.

  9. #9
    Join Date
    Oct 2006
    Posts
    381

    Default Re: Prescription Rule Changes

    Did you get my pm Tony? I am not able to find any indication that it was sent or received.

    Quote Quoting tony View Post
    GregI don't see them making overpayments for that long without catching it, there has to be an error - that's way too much for an overpayment.

    Did you file for a reconsideration when you received the notice of overpayment?
    If this is the appeal you're referring to, they should continue payments until the dispute is settled.
    If you're awaiting an appeal on the determination of reconsideration, they should afford you the opportunity to make payments "at the rate of the lesser of 10 percent or the entire monthly payment;"
    It's very unusual for them to withhold the entire payment, I've never heard of it.

    WHAT WILL WE DO IF THERE IS AN OVERPAYMENT?
    We will send you a notice explaining the overpayment and asking for a full refund within 30 days. If you are currently getting payments and you do not make a full refund, the notice will:
    propose to withhold the overpayment at the rate of the lesser of 10 percent or the entire monthly payment;

    state the month the proposed withholding will start;
    fully explain your appeal rights;
    explain how you can ask us to review and waive the overpayment, so you may not have to pay it back; and
    explain how you can appeal our decision.

    WHAT CAN YOU DO IF YOU GET AN OVERPAYMENT NOTICE?
    If you believe you were not overpaid, you may request a reconsideration.
    If you ask for an appeal within 10 days from the date you receive the notice, any payment we are currently making will continue until we make a determination.
    https://www.ssa.gov/ssi/text-overpay-ussi.htm

    Tony
    The matter is long and involved Tony. Thanks for asking. I'll try to keep it as short as I can.

    In January or February of 2006 I filed a Social Security Disability Claim. It was awarded and payments began in January of 2008. During the intervening two years I collected WL and TT during a Michigan state sponsored rehab plan and medical treatment for my industrial injuries. Subsequent to that SS award determination I was again paid TT during wc allowed medical tx. All of those wc payments were temporary and sporadic during that nine year period. I did not report them for reasons I will explain. When I was awarded PTD from the State of Ohio I began bi-weekly PTD benefits every two weeks effective March or April of 2015 and received a lump sum payment retroactive to the date of the physical opinion that stated that I am permanently disabled. I reported the wc PTD award immediately to the SS Administration at my local office in May of 2015. In June of 2016 SS advised me that I was overpaid. A lot. There was no detailed information at that time to explain, I have requested it, and it takes up to 90 days for SS to deliver it to me. I am waiting. I am reluctant to post the numbers here in public.


    In August of 2016 I filed a request for waiver and another for appeal. The most recent SS case worker I talked to insisted that I repay the entire alleged overpayment, and that they were taking my entire SS benefit. They will not budge. Regardless that I too had thought that the SS payments would continue until the appeal was resolved, they took it in its entirety. They are adamant about that and refuse to take smaller monthly payments, to include the 10% you mention. I am waiting for my appeal hearing to be scheduled. I am paying my Medicare and Advantage plan premiums out of pocket, it is killing me, and am considering Medicaid If I am eligible, which will be pretty close. I got with a SS attorney who met with me at the nearest hearing office where my file resides and reviewed it. He is uncertain how or why the overpayment was arrived at. He gave me a formula for a method to find that. It is to be broken out month by month (I have to learn now how to use spreadsheets) and is: workers' comp paid (D), less my Average Current Earnings (which is arrived at at a different formula and is designated ACE and (A) for the purpose of this computation plus Social Security paid (B). IOW, D-(A+B). I am frustrated. I have found that SS overpayments can be discharged in bankruptcy and am toying with that. I also took a cash advance on my future PTD benefits to by a house, am paying it back out of my wc benefit at 4%, and am trying to find out if that can also be discharged. I have contacted a bankruptcy attorney.

    The reasons I did not report the wc benefits to SS are a mess. I was in unspeakable pain throughout, fighting resistance from wc to treat me, taking immense time and energy. I was at one point evicted from my home because a local doctor had screwed up my wc tx immensely and I had lost my benefits, had no means of support, and my financial life was ruined, as if it were not well on its way beforehand. My wife was barely ambulatory and dying, and it fell to me to be her full time caregiver. She had become horrifically sick in 2002 and died in September, 2014. She fell frequently, toward the end about a dozen times a week, and I often saw her get on her feet and her knees begin to buckle: a sure sign she was falling. I had told her not to get up for any reason without telling me so I could help her, but she had lost most of her cognition due to multiple ischemas. I caught her to break her fall and then helped her back into bed or chair as best I could. I could not always make it in time and that tore me up bad. There were times I was not around, taking care of important personal business and seeing doctors, and arrived home to find her sprawled on the floor with injuries, to include concussion. My nearby kids were little to no help. Hiring help was not possible. Lifting her up and down aggravated my conditions, both those that are and are not allowed in my wc claim but should rightly have been. For long periods of time I was barely ambulatory myself with pain, could not use my arms, legs, or shoulders without further injury, and nonetheless had to be there for her. There were more than an hundred hospital admissions with her, and I had some of my own. Throughout I was getting facet joint injections, epidurals, trigger point injections, massage, PT, and surgery, eating all the pain killers I could legitimately get my hands on, along with cannabis which is allowed in my state, and alcohol. this last to include spirits at the very end which fukd me up bad. I had prior to the substance abuse become psychotic on a few occasions, and was clinically depressed throughout, with debilitating bouts of panic and mania. I was dx'd with bipolar disorder in February, 2006. That condition and symptoms have been very, very much resolved after her death, and it became obvious afterward how circumstance had played to debilitate me both physically and mentally. I did not use spirits or cannabis prior to this ordeal, and will not again. I lived in daily terror. There was no room for anything else.

    Thanks for your obvious concern and advice.
    Last edited by Greg; 03-17-2017 at 12:50 PM.

  10. #10
    Join Date
    Oct 1971
    Posts
    5,059

    Default Re: Prescription Rule Changes

    Greg
    Did you get my pm Tony?
    Nope.

    All of those wc payments were temporary and sporadic during that nine year period. I did not report them for reasons I will explain.
    The reasons I did not report the wc benefits to SS are a mess.
    Regardless of the reason, if you where overpaid, you'll have to pay it back - if you have a valid reason, the most they will do is not press fraud charges.

    Tony
    Moderator Responses are based on my personal bias, experience and research - They do not represent the views of the admin nor may be accepted in the legal community, always consult an attorney.

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