NeuroTalk Support Groups - View Single Post

tshadow · 01-17-2008, 03:05 PM

Nobody here should attempt to answer this question as the complexities are so vast that not only does a work comp attorney deal with it, but they hire (often) an outside firm to help them with their computation of future medical and how to deal with Medicare.

The basic, general principle is that IF you get money from work comp to cover an injury for future medical, then Medicare is obviously NOT going to give you treatment for that injury unless and until you have spent the money you were already given for the injury. AND, if you did not go through the proper channels of having Medicare sign off on it, and there is too much to list the amounts, etc., here, then Medicare can say, "you blew it, you didn't get enough money from your work comp and that's your problem not ours."

Illustration. Person has work injury and knees get replaced and have future medical. They determine the future med is $200K, and that represents the life value, and then they also can figure in your permanent disability and / or vocational rehabilitation - and other factors depending upon the state. But let's say the person takes that lump sum money and goes and puts it down on a house and buys a car. Then they turn around and ask Medicare to pay their medical treatment on their knees. They risk Medicare being savvy to the situation, and flat out refusing to pay for any medical care. Or, sometimes it is a matter of treatment to the entire lower extremity, and Medicare may fight it out that it is still just an anticipated extension of the original work comp injury, and again argue that the person has already been compensated adequately to pay cash for their medical care and they should not be coming to Medicare for treatment. The multiple situations one can think up can be mind-boggling, and so it goes back to one's attorney and one's own set of facts and risks and anticipated medical needs.

The point is, if you've already been paid by one insurance co. for the VALUE of your FUTURE medical care, then the Federal government should also not then have to pay on top of that - you'd be given a windfall that wasn't earned.

This issue is not an easy one, and depending upon how ill one is, and most of us TOSers need a LOT of costly care, then one has to wonder if it is even WISE (???) to bail out of your medical care with work comp and do a lump sum agreement - what is known as a Compromise and Release in CA. The emphasis is on RELEASE, once you've made that deal, it is very hard to undo them or go back later and say, I didn't understand...or that wasn't enough...etc. And then there are situations where the case is not admitted, and it is truly a disputed issue, and then how Medicare would handle that is different also. But the basic concept is, if you have an admitted work comp injury, then the insurance co. / employer on duty for that injury, should and is held responsible for the medical care for that injury. During the 80's and 90's waaay too many people were taking a quick BIG buck to settle their claim, only to turn around and ask Medicare to pay for a surgery and more...and Medicare wised up on it, and now holds people responsible for this situation. So what Medicare may or may not cover is entirely individual and according to the facts of the individual work comp case, and no one can really say what Medicare might or might not pay for, or how quickly, in any work comp setting. I know in my situation that I am having trouble getting ANY Medicare / Gap treatment, as I have an open work comp case, and they are mistakenly refusing me ANY medical treatment when my case is limited to certain body parts. So, except for an emergency room basis, I have actually gone to a doctor's appt. for a non-work issue, and been told that the doc won't see me because I have an active work comp case, and they don't want to cross any legal lines by giving me treatment when it should be paid for by the work comp carrier. (I'm an attorney and they pull this stuff on me, and my fiance does faxes and has to make a bunch of calls, etc., to clear it up. So any work comp settlement should by this example be so very clear, as to avoid these confusing situations.)

I am NOT giving legal advice out on this one. This is a question that should ONLY be discussed by the person and their attorneys, and GREAT thought put into it. No one who is not an expert in this field, (and I am not by the way), should be attempting to ANSWER this question, other than to advise to go ask your attorney.

This is not to be fussy, but just this is such a serious, absolutely serious issue. Back to bed for me. Saw this a couple of times, and just didn't feel like I could let it go...