[ThreeForOne]

For people covered by Medicare, how well are treatments for TOS/brachial plexopathy covered?

I have a good chance of being on Medicare this year assuming my SSDI appeal is successful. My workers comp attorney wants to settle the medical portion of my workers comp claim, under the assumption that Medicare would cover most of my medical costs, and that Medicare would be easier to deal with than the workers comp carrier over the long-term.

I'm concerned about how much of my current nonmedication treatments (massage therapy on neck and arms for brachial plexopathy at outpatient physical therapy center, hard and soft splints for inoperable carpal tunnel that need periodic replacement) , would be covered, as well as future treatment options (surgery if needed, etc.). I'm also taking Lyrica for nerve pain.

I did hear from my pain management doctor's office that the outpatient lidocaine infusions I get twice year for type 2 CRPS (RSD related to the brachial plexus injury) is not covered by Medicare, because they consider it "experimental."

Also, looking at the Medicare web site, I found that there is a $1780 per year limit on outpatient physical therapy for Pennsylvania.

Has Medigap insurance (the type that includes coverage for "Part B Excess Charges") been helpful in covering payment for treatments not specifically covered by Medicare B or where physical therapy, etc. is needed beyond the medicare cap amount?

Thanks

ThreeforOne

[Jomar]

I'll copy this question to the Social Security Disability forum also, as
similar chronic treatments could apply for others there and they may have some knowledge about it.
http://neurotalk.psychcentral.com/forum28.html

[lisa_tos]

The basic process for transferring to Medicare is that you and the work comp insurance company do an estimate of what your future medical costs are likely to be under Medicare, an MSA, and then you close your work comp case. At that point, Medicare reviews the estimate and decides if it will be accepted. If the estimate is too low, you can end up in a situation where Medicare will not sign off on the deal so you can not get Medicare coverage but you no longer have work comp coverage because you closed your work comp case. So the estimate needs to be done correctly. medications in particular are complicated because Medicare D. doesn't cover very much. I'm not quite sure how to set it up properly to cover medications but I think it is in fact possible.

The MSA only covers what Medicare covers. Medicare does not cover or co-pays for Medicare, I believe that has to be separately negotiated.

Medicare plus Medigap covers
1) a small amount of medications
2) trigger point injections
3) surgery
4) MRIs and other diagnostic tests if clinically indicated.
5) physical therapy that can be shown to produce functional gains, physical therapy/massage therapy for pain relief is not covered. There is a cap on physical therapy as you mentioned. You can get somewhat more physical therapy if you are getting it at an outpatient clinic attached to a hospital, but still there are limits.
6) Pain psychology is covered I think up to 30 visits a year, probably also with the requirement that you are getting gains.
7) I think certain kinds of nerve blocks are covered, but I'm not sure which.

If you are very poor, you might qualify for some attendant care through another government program.

[tshadow]

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...

[lisa_tos]

Tshadow gave a more complete answer but I did want to clarify the reason for my post.

My attorney tried to get me to sign a C&R even though the MSA was done totally incorrectly. If I had not got a copy to look at myself, I would not have known it was wrong. So it good to know what to look for in an estimate.

The attorney was trying to convince me it would go through Medicare. (He later admitted that I was right to suspect it would not go through.)

There are some unreputable firms doing MSA estimates. I've seen a $25,000 estimate for a million dollar injury.

[lisa_tos]

A few further comments on how to check an MSA estimate. I agree with Tshadow that it's really best if you have an attorney who is working with you to make sure it's correct. I'm sure I don't know enough to tell if one is done correctly so my comments above what Medicare will cover do need to be evaluated in light of your specific situation with an attorney and an experienced reputable firm that does MSA estimates.

However here are some red flags that the estimate is not correct. you would probably need someone with out TOS to help you do this because it's too much paperwork.

1) you can find out from Medicare what diagnosis codes your injury is reported to be. You can find out from your treating physician what diagnosis codes he or she thinks you injury corresponds to. You can look at the MSA estimate to see what diagnosis codes for your injury are included. Everything according to Medicare is keyed off of what they think the diagnosis codes for your injury is, so if there are discrepancies you might want to ask about. It takes a professional to figure out how best to summarize your injury in terms of diagnosis codes to report to Medicare so there may be reasons for the discrepancies you find, but the professionals should be able to explain it to you.

2) if you know somebody who is getting similar treatment under Medicare, you can see what procedure codes are typically used for the services your doctors say you need. It's really common for a service to have a number of procedure codes. The firm that did my estimate would only put one code for procedures that had multiple codes. This resulted in gross underestimate of some procedures-one procedure had only 1% of the actual typical cost estimated because all of the expensive codes were excluded.

3) You can check if all of the prescriptions for medical services were served to the estimator. Medicare looks at all the things you're treating physician has been recommending in the last several years for the diagnosis codes it believes your injury consists of. So if your doctor recommended something expensive like surgery for one of the diagnosis codes Medicare has and the estimator has not reviewed the current prescription for that expensive medical service, you can have problems.

[fern]

my response is for medicare only and has nothing to do w/WC as I do not have experience in that area.

I suggest that you go to medicare.gov or get the book "medicare and you--2008" and look into the health plans you qualify for in your area. The plans vary quite a bit in diff. states and diff zipcodes. You can do the research yourself and you can see a counselor in your area to get started. There are several different styles of plans and you would want to figure out which kind suites you best if you are going to go on Medicare. You have to realize that there is a waiting period from the time you get SSDI to when you get Medicare. I think it's 24 mos--- but that may not apply as you mentioned that you are appealing.

I have been mostly happy with my experiences. I have tried both an advantage plan that replaces Medicare and now am on a supplement. It can take some work and creative problem solving but by in large I've gotten to see each doctor that I wanted. On the HMO Advantage Plan I sometimes had to see one or more of their doctors before I could go out of the network but I was never denied a consult and surgery but I'd have to make a request and possible appeal (which can take some effort and time). I was denied ongoing treatment w/a neurologist I preferred so I paid out-of-pocket. And things like massage therapy aren't covered at all. One time I switched groups w/in my plan to be able to see a certain PT. Not all the drugs are on the plan formularies but I've been able to petition for drugs and quantities and even lower copay amounts. The dollar limits for things like drugs and PT can be problematic if you need a lot so if you have an option to continue on something better you may want to consider that too. But you have to evaluate if you are penalized by not taking Medicare. It's a case by case issue and you basically have to research all of your options.