Medicare and Denied Treatment

Saturday, May 20, 2006 | 0

The following was recently posted in the Injured Workers' section of the WorkCompForums. The editors felt the information was important and have republished it here, edited for readability, grammar and spelling -

To injured workers (IWs) receiving Medicare who have been denied surgery or other treatment by your AME doctor:

If you have Medicare for being 62 or over, and you have a WC claim besides, then this info will not help you.

If you have Medicare for being severely disabled, and are currently receiving both SSDI benefits and WC benefits (TTD or PD) ongoing monthly, then information mat apply.

In one case, the first Agreed Medical Examiner (AME) appointment revealed a super-quack with lots of clout. So for their second AME appointment, the claimant brought along a certified court reporter, assuming she would have to pay for the service. However, the insurance company (IC) was billed, stating they were required to do that (by a WC Labor Code) whenever the IC has set up the appointment, and is requiring the IW to attend. (One should keep the letter that demands your presence at the AME's office). After the second AME visit, she received a copy of the transcription from the court-reporting company; the IC also received one, and she sent a copy to their AA.

The claimant's primary treating physicians (PTP) both offered to refer them to a fifth surgeon regarding spine surgery on their neck. She then asked their attorney (AA) which to use, and was told that either one would be fine. She chose the PTP. The PTP sent a full-page referral letter, and a huge stack of documents to UC Davis Neurosurgery Department, and about three weeks later she received the YES letter that the surgeon they had found on the internet would examine them and look at her films!

On the subject of Social Security, since being granted the SSDI in 2004, the claimant had never sent anything to the SSA by mail. Everything was taken to the local office, where she waited until they were assisted by a clerk, and could make sure that they knew why she was giving them these papers, or ask a question, etc. She hardly ever call them anymore either, because many times they had received incorrect information from over the phone. If you have time, go there.

When the claimant need treatment that was denied in an AME report, she give the clerk her Medicare and Blue Cross cards, and explained it had been denied.

It is highly recommend that you call the CMS office that handles "Coordination of Benefits." This is a legal office, and everything that you say will be recorded and everything you send in writing will go on your permanent record. So make sure of all of your facts and don't guess about anything. Tell them you need certain treatment for a WC injury, and that your AME has denied it. Your case will then become highlighted on their computer as being a "third party" case. Before you call them, have some paperwork with you so that you can give all of the names, addresses and phone numbers for your IC, DA, CA and AA as well as your IC claim number and your WCAB number. Also all of the ICD-9 codes of your WC injury diagnoses from your PTP. The more info you can provide them, the better it'll be for you.

If you also have a Medigap policy or a Medicare Advantage HMO or similar insurance, or if you have MediCal secondary to Medicare, then it is highly recommend that you call that insurance company or agency as well. Ask for their "Coordination of Benefits" office or "Third Party" office. Give them the same info that you gave the Medicare folks.

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