Worried I am not getting PROPER MEDICAL TREATMENT THROUGH WORKERS COMP.
 

I was injured at work on 3-25-09, Fracture to right great toe, I have MRI, CT SCANS, X-RAYS, have seen around 50 doctors, 1 not a MPN doctor my first attorney sent me to that states I have CRPS, I went to a QME March 30, 2010, that has stated I basically am lying, after that I was sent to new PMD, that went over QME report and my last Dr. report, he says I have CRPS, then we found out my last PMD with held an x-ray report that shows in my right foot sever bone demineralisation, sever bone decay, I feel now it has become an emergency situation, W/C in Ca. allows insurance carriers the obligation to maintain responsibilities, therefor, to receive proper medical treatment, they have to approve it first, however, I had an appt. to see specialist who was only asking me to produce were the MRI, CT RESULTS & ANY X-RAYS. Do I have a right to go to an ER with these same documents and receive treatment without financial responsibility, providing proof of services rendered clearly relates to original work injury? Thank you for all your replies I'm not sure what I have a right to do.:(

I am not looking for legal advise, I am just looking for suggestions thanks so much!

Azaila, I too am a WC patient in Ohio. I know that the laws vary from state to state. My attorney told me that it is very rare for WC to pay for ER visits here in Ohio. There is a very good link through this site for WC questions where you may find more helpful information. Unfortunatly it seems like what they are best at is denying treatment and making you jump through hoops. I am beginning to give up hope that I will ever get the treatment that I need, but wish you better luck. Lisa

I am also a victim of WC.

Often when I have needed treatment for my RSD I have pulled out my private insurance card (United Health) and used it when WC has refused to pay - at the pharmacy, for PT, and for medical procedures. My lawyer spent hours transferring charges from United Health to the Hartford last year when WC finally decided to accept responsibility for a raft of charges that had accumulated over a period of several months. Not my problem.... of course, I also had to come up with a co-pay in many instances, but it was better than going without anything at all.

If you have secondary insurance, see if you can use it to get the services you need.

Good luck, WC sucks. Try not to get too stressed out about it. Sandy

I can help a bit. I'm also in CA and have been in the WC system since 99.


The bad news: since the WC "reform" here, you have even fewer rights than I do.

The QME's for the insurance co. are not on your side. It sucks, because you assume all docs care about helping and healing you, that isn't what their function is in this case.

I can't imagine how you've seen so many doctors? The laws here are written to keep that from happening.

What you need to focus on is your care under your Primary Treating Physician. You should preferably have someone with RSD patients. If you haven't had any blocks yet, that would be something to discuss. You need to start testing meds out, it'll be a long process of trial and error.

Going to the ER is a quick fix to a long term problem. I'd make an emergency appt. with my WC Primary if I were you. Also buy a book on CA WC laws to understand the system. NOLO publishing should have one.

http://neurotalk.psychcentral.com/thread106250.html

I'd check out the above thread, btw.

Our WC forum- Layoffs, Unemployment and Worker's Compensation =
http://neurotalk.psychcentral.com/forum30.html

might find some useful info there also.

My husband has read the W/C books and also read the rules and everything online about W/c, and what to do, I wish I knew ahead of time to look for an attrny that deals with CRPS I just didn't know there were so many cases. Thank you all for your replies!

Azalia,

Hello. I am dealing with the added frustration of WC too, but I am in Mass. I've read on here that California does WC a little differently and people are having very specific issues with having to go through multiple URs and getting nothing but denials.

A great resource is one of our posters tshadow. Here is a recent thread: http://neurotalk.psychcentral.com/thread116994.html

tshadow and ocelyn are both very knowledgable and vocal advocates for NeuroTalk'ers in California and dealing with WC. They are trying to gather stats and support to help people battle WC. They both have TOS and RSD, but tend to be found mostly on the TOS forum here.

Hi Azaila,
I am in CA and have a WC case as well..
First and foremost, let your ins. company know you are well-informed, aware, and educated about RSD, protocols for treatment, and the rights you do have with a WC case. This will make them aware that you just 'won't go away' a..make it clear that you are not going to give up and will fight for treatment..assertively and 'diplomatically..'
Then, make sure you have an attorney who is familiar with RSD and its implications..
The inusrance company wanted me to have a QME with someone whom I thought was not a qualified specialist and I let them know I was aware of this.
At that point, I did get an attorney because I knew they were going to play 'hardball'. I didn't attend that QME and had another one rescheduled.
Keep us posted and good luck...don't give up!
Hope4thebest xox

Azaila
 

Unfortunatley, being a w/c patient the insurer can rightly deny any and all ER claims. You need to be followed up by your w/c physician. Go often, go as much as you need to go relating to your injury. I found out the ER issue the hard way. So, its true. The rules state you must get permission to go to the ER from the insurer. LOL...so when do we know when the ER is needed? O yeah, I plan on having SOB, my extremities will be turning blue and pain so high it cannot breathe on Saturday 1:56am. Its called dictated medical care. However, the insurer will pay for true life threatening conditions which they put conditions on.

1 instance I had a severe reaction to a medication...I went to the ER from work and was reprimanded by the insurance company that i should have gone to the clinic. They couldnt have helped me, I needed ER attention and meds the clinic didnt offer. Another time I couldnt breathe not knowing I developed pleurisy from a w/c procedure needle poke. Well, I had to have a PET, MRI's & CAT with contrast, then drain my lungs as in a thoracentesis. 2 weeks worth of testing and hospitalizations. They refuse to pay for it to this day since it was not approved before going to the ER. It was a weekend. What is a person supposed to do?

My former PMD told me i should immediately go to the ER so my husband took me, now what do we do? Thanks so much again!

My former wc claim was denied but I got treatment using my pvt medical ins as the secondary insurer.
I can't recall if my atty suggested that or how it came about. Maybe the billing dept of the PT place.. came up with it.
this was in Oregon, not CA.

But treatment was for the wc injury so it was listed as Ins #1 and my pvt medical was as secondary payer.

and also since my claim denial was being appealed all bills could be placed on hold. {atty wrote a letter to billers}.

So nearing the end {hearing/settlement} all bills on hold had to be gathered up and listed - some were paid directly by the insurer and some were left for me to pay out of the settlement.

If you have an approved and accepted claim this may not help much..

Unfortunately wc does not really seem to care if you get proper care or not...:mad:

You have to do what is needed for your best care, if you can figure out a way to get treatment without messing up your claim..

I did go out on my own and pay a bit of cash to a chiro & PT person for some specific help - and they were the best help I got...!

But I had/have an RSI/TOS injury and not RSD.

This might make you laugh......

I've had 1 ER visit for my neck pain/RSD basically for meds. I had Vicodin 7.5/750 mg q 4 hours prn. I had a flare that required I use it q 4 hours when I normally only took 1 or 2 a day. Every 4 hours was too much Tylenol, primary was supposed to call in a script without Tylenol, but didn't and covering MD told me to go to the ER. I told ER doc the issue and he wrote a script. No exam, no tests, just gave me what I needed

WC denied the visit.

Prior to my injury, I worked for the hospital. That hospital's WC denied my visit to their own ER. Doh !

Because they have my regular insurance info on file, the hospital just billed my normal health insurance, who paid it, BUT......I got sent the bill for the deductible. I refused to pay it. I actually surprised my insurance covered it.....no exam, no treatment, just the script.

And now my credit rating has one big glaring negative........that stinking $25 co-pay

Worried I am not getting PROPER MEDICAL TREATMENT THROUGH WORKERS COMP.
 

Azaila - Here is a creative thought. Even if compensation were not an issue, an ER is not a dependable source of care for RSD.

I am not an expert in workers comp., other than to know that in CA the docs do not get paid until your case is settled, making a financial disincentive for them to take WC cases. I noticed that you live in L.A. Among the best treatment in CA for RSD is at the UCSF Pain Management Center. Because they are a government-funded center, they must accept all patients. The catch is that they require a referral from another physician (this could even be your internist) and act on a consultant basis (they see you on a regular basis, treat you (i.e. stellate blocks), and determine your prescriptions. But your on-going management for your medications between your appointments @ UCSF is taken over by your referring physician (i.e. your internist).

UCSF has physicians who do research into RSD, and patients with RSD are treated with respect and credibility. You would not need to produce your MRI, CT Scans, or X-Rays, because they know that none of these are tools used to diagnose RSD. UCSF is only a one-hour plane flight away on inexpensive Southwest. Your travel expenses tax deductible.

Do you have any doctor who can write you a simple letter of referral? You can get the simple procedure from their website or by calling them and your internist can be used as the referring physician. You would have the some of best medical care in the state and I think they have to accept your WC.

WC makes it difficult to get good care. This might be a way to get the best.

Skooz: Primary Treating Physicians do not have to wait for your case to be wrapped up before being paid for WC. There are many reasons why docs dislike the WC system in CA, but that isn't one of them.

Also, WC would not allow her to travel to SF for care. They would be responsible for her travel and accomodations.

OP: Your PMD told you to go to the ER, because they get sick of urgent/emergency calls from pain patients. It won't make it covered by the insurance.

A PMD often won't be able to accomodate getting you in early because their patients are so much needier than a normal doc's. So that their lives don't become over run by pain patients, they are less accomodating, not more. That is why choosing a Primary Treating Physician you can develop a relationship with is so important. Did the ER visit accomplish anything?

Your initial post made it sound like you were interested in finding the right care, now it seems what this is really about is a billing question. Call your attorney, he/she should deal with it.

If your husband has become well versed on the CA WC system, he should have told you the problem with getting WC to pay for an ER visit. If you have RSD, you'll be dealing with the WC system for a very long time. It would be in your best interest to put your energy into finding a Primary Treating Physician and personally learning about the very complicated WC system here in CA.