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I hate Workers Comp

outofcontrolooutofcontrol Posts: 264
edited 06/11/2012 - 8:50 AM in Health Insurance Issues
The last time I went to my PM doc, he switched me from Oxycontin OP to MS Contin ER because it was cheaper, and WC had contacted him and requested that he try it.
I have had so many problems with WC denying injections, SCS, NS second opinion consult--it just makes me so mad!! I did not ask to be here-and I wish that this was NOT a WC claim!!! However, I hurt myself at work, and I really thought that they would live up to their word and take care of the problem.
The PM doc I see is the one they referred me to. Now I wonder if he is just telling me that things are denied by WC so that I won't think that he is the one who is not providing treatment.
I is sad to not trust the people that are supposed to be taking care of you.


  • dilaurodilauro ConnecticutPosts: 9,859
    are probably the most difficult and frustrating things to deal with.

    Without any of the above, we can pick the doctor we want, we can decide what treatments appear to be best for us, and the list goes on.

    Not so for WC and VA items. From everything I have read and understood, there are so many restrictions that getting to the source that can really help you is so difficult.

    I dont fully understand all the ramifications in dealing with WC, since I have never been in those shoes, but I do understand that it is very difficult and frustrating.
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • It just seems to me that if you get hurt on the job, and there is absolutely not a shred of doubt that you were hurt on the job,(the company totally agrees that you were hurt on the job) then they would do whatever needed done to treat your injury.
    Haha--it's looking like another bad day here!!! Crap-they make me so mad!! ~X(
  • Wow I had no idea that WC tell your Dr. what to prescribe but hope it's working for you and if it isn't I would tell him. I didn't realize that they have so much say over your medical treatment injections and second opinion. Do they have some information of what they can really provide? It's rough to deal with LTD as well for me but don't have the restraints of WC. I hope you get the right treatment for you. Are you going to Physiotherapy and other treatments to help? Thinking of you. Charry
    DDD of lumbar spine with sciatica to left hip,leg and foot. L4-L5 posterior disc bulge with prominent facets, L5-S1 prominent facets with a posterior osteocartilaginous bar. Mild bilateral foraminal narrowing c-spine c4-c7 RN
  • Hi, there is a very good chance that the PM is nto being completely honest with you.
    Are you still under the care of your surgeon?
    If so ask him/her to "refer" you to another PM, then it is not considered using up your 2 choices of doctor's under the comp laws.

    Work comp can be very diffucult, as you know, amd if they can save money they will.
    Do you have a lawyer?
    They can help pressure comp. to approve the NS second opinion.

    I'm on comp. and i've been down that road before so if you have any more questions let me know, and i could probably help you out.

    Remember a referal is not considered you using your 2 choice's of doctor's, tho the 2nd opinion doctor will probably insist that comp. approve it 1st so they know they will be paid.

    Good luck
  • My husband has been on Comp and it was very good. In his case it was a union self insuring plan so the medical part was a division of the regular medical department. But it was similar to a managed care in that everything had to be preapproved by the case manager. I learned early on to find out who that was and make friends. And most important get phone and fax numbers.

    Something that is very important to keep in mind with workers compensation is that what is spent on your care usually gets deducted from any "loss of use" payout when your claim is closed. Find out what your plan covers now because you may be hurting yourself with unnecessary tests or procedures.

    And remember, those people at the insurance companies and doctors offices are just people like you and me. They don't own the company and they sure don't make the rules. So try to make friends and ask questions. This is one time where I swear you will get more with a few nice words than an attitude.
  • Kris is correct talk nice to your adjustor.

    But comp does have doctor's on retainer who review your info. and make their recommendations on what is reasonably necessary.

    State laws vary.
    In Illinois your medical treatment is not considered part of your final award, for the injury. Meaning all the cost's of medical treatment, will not make your settlement any smaller.

    You have to look at your state's comp. website, or ask a lawyer in your state.
  • I get along well with my claims adjustor. When I had a case manager, we got along really well, and I think having her involved really helped my situation.
    Once I was switched to PM, and no longer seeing the NS, the Case Manager was taken off my case.

    Now the office staff at the PM office deal with the Claims Adjustor about any injections or treatment changes.

    The only time I contact the Claims Adjustor is when I have a problem getting my medications refilled. If I ask her about consultations with a new NS, she says she will look into it, and never gets back to me. So I call her a few times--she says she is still working on it-and finally I just let it go.

    I hate to even think that the PM might not be providing the best treatment possible in an effort to save WC money, but it does make sense---WC is paying him, WC refers patients to him---financially, it is in his best interest to keep WC happy.

    Hope everyone is having a good day!!
  • My first question to the case manager would be "who determines what treatment I receive, the doctor or you?". This should answer the question of whether they are denying the injections or if the doctor is tailoring your treatment to keep the company happy. I would also try to get something in writing from both the WC provider and the doctor office saying that they are denying what the doctor ordered.

    Then it would seem you have three options.

    1 - you do nothing and continue to get the same treatment.

    2 - you call the case manager and explain that you are not happy and expect her to take action to get your treatment approved in a timely manner. If she doesn't you contact her supervisor and get a new case manager. It is your right.

    3 - call the case manager and request a new pain management doctor.

    You have a right to get good treatment in a reasonable amount of time. This includes the treatment you receive from the case manager. Be nice at all times. Be clear about what you want. And be reasonable in your expectation.

  • It the "lovely" world of workers compensation, things get really complicated. My doctors always have to submit a request for approval of treatment. I was recently referred for evaluation by an out of state facility and workers comp denied coverage stating it was medically unnecessary. I still went under my private insurance and got more help there than I have had over the 4+ years since my injury.

    My doctor here once went on a vent, expressing his frustration about how WC can have people with high school educations sitting in a cubicle denying coverage for procedures. But they do it every day. You just have to be persistent and submit the request over and over again, with notes explaining again why the doctor feels it necessary, and sometimes they will give in and approve. Sometimes not.

    I also just went for evaluation for a pain pump. All of this is undeniably related to my work injury. The referral was appropriately made. WC denies coverage even for the consultation with the pain pump doctor. Just another example.

    If I had it to do over again, I would have never reported my on the job injury. Life would be so much easier if I could have just gone through my primary insurance.

    Outofcontrol, I get everything you are saying. Don't know what state you are in, but I tend to believe your doctor that WC is denying coverage. If you are suspicious though, call your adjuster. Or ask to see the denial. Also, it took me 2 years to get an attorney. If you are having this much difficulty getting meds filled and other treatment, maybe it is time to find one. But once you do, keep in mind that you won't be able to communicate with your adjuster anymore and it will all be handled by your attorney and doctors. I would love to pick up the phone and have a stern conversation with the powers that be, but my hands are tied now. Whatever you do, don't settle your claim without consulting an attorney.

    Surviving chronic pain one day at a time, praying for a reprieve because living another 40 years like this doesn't sound too fun!
  • I second Neck of steels comment. I seriously doubt your doctor is the one whom is denying your treatment. First off he has everything to gain as it is more money for him. I have gone my gammit with work comp. I like Cindy wish i was never made work comp, in fact I cried when I was forced to turn it in, even getting on my knees begging not to be a work comp patient. While back then I had never had a claim, everything I have heard about them has come true. They are my living night mare and never go away. I am at the MMI point were they say there is nothing more they can do. Well not so this past summer with a court order of them showing they will only pay for meds now I had another 360 fusion. Today I get a email from my attorney saying just letting you know work comp is cutting you off from pain management once again. Now the fact is every doctor they have sent me to has confirmed nerve damage and some other issues and stated with medical certainity i will need the meds for the remainder of my life. But here we go I am cut off till I get a new court order, the emergency department will be on my list of things to do when I go in with draws in two weeks.

    My point is I trust your doctor. Your doctor can show you the denial letters as well. Sometimes if you contact the business office they will be happy to give to you, if you say they said you won't approve it. but they did. But I am with Cindy in thinking it is your carrier.

    Keep in minds the laws very by state and you might not have the oppurtunity to change doctors. Sometimes you can do a one time change and then if you don't like that person you are stuck and I mean stuck big time. The insurance job is to keep the amount of the claim down, but lead you to believe they are helping you. In the end they can say well you must have not needed it to begin with. Okay I am really pissy on work comp today after that denial letter coming through so maybe i am really biased today. But no matter I have said from the get go nothing good can come out of having someone sitting in a office involved with your medical care when they have a financial interest in it.
  • jlrfryejjlrfrye ohioPosts: 1,110
    My first question to the doctor would be why is it denied? If the doctors staff does not specialize in WC there could be reasons due to the fault of the office. WC requires a form for everything. Medication change, test and procedures. I would call my case worker and ask why it is denied. They will tell you if a form or protocol for a procedure was not followed. If the doctor adds one diagnosis on the claim that has not yet been allowed the claim is denied. Yes you have to fill out a form to add a diagnosis to the patients claims. Im serious when I say there is a form for everything. Many doctors in my area refuse to take WC due to the problems of getting claims paid. Work very close with your WC rep and she will help you navigate the WC system.
  • Thanks for all the replies.
    I see my doc on Monday and I have a lot of information and a lot of questions that I want to cover with him. I hope it goes well. I really, really like him. Everyone please send good thoughts my way!!!
  • One last thought. WHen you speak to your doctor he will likely give you a blank stare because he doesn't do the paperwork. He will have a general opinion about how WC pays him but that's it.

    Explain what has been going on and then maybe ask to speak to his office manager or whoever does the claim submission. I would ask for a complete copy of your file including copies of all submissions to the WC carrier. It's your right so don't let them talk you out of it.

    GOod luck and I can't wait to hear how it goes. Remember to be clear in stating the problem and clearly state what you want them to do.
  • One thing I can suggest if your asking questions of a doctor and then say you want the medical records in the next sentence they will become somewhat defensive. In most states it is the law the carrier provide you with a copy of the records. I happen to be very lucky that all my doctors are very aware of how each insurance company works and what they need to do. I have learned through some of my hot headiness to work with the office manager, or in one case they have one person maintaining all work comp patients. Make that person your friend, as trust me work comp is making them their friend as well. It is not a unique to one doctor office or one practice. If they are taking work comp, typically they been dealing with it for a long time. I hate to say this but keep in mind for all of those whom have played a game with the system, the rest of us pay the price, to a degree. I will tell you there is a reason doctors take work comp as it can be fairly lucrative business. Meaning depending on the size of the carrier and their location they may not have good contract rates. So if you were working for a national company in any given area they may not have it supported as well as they might in another area.

    If you like this doctor and feel he is helping you, go with your intuition that it is not him, but rather happening from work comp. He has nothing to gain to offer a treatment model and then not provide it. His goal is to get you as good as he can get you and either your better or on a maintenance program.
  • Best of luck monday with your doctor appointment.
  • MetalneckMetalneck Island of Misfit toysPosts: 1,364
    Oxycontin is over 3x more expensive than MS Contin.

    Managing costs at the potential of your on going comfort.

    "WC Managed Care" ha ha!

    Best wishes,

    Spine-health Moderator
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