OT Variable Rate Insurance claims?

Pete was denied his meds by Workers' Comp, and the answers he's getting
reminds me of the variable rate housing crisis. It seems his employer paid
an insurer for Workmen's Comp. That insurer sends the claims to an
insurance adjuster. And the insurance adjuster has turned it over to Third
Party, or is it a third party, and they're saying his meds now cost too
much.

Of course, chronic pain gets worse, not better. And drugs lose their
potency. And new drugs cost more. So, yeah, I guess the costs to them have
increased. But like with the adjustable mortgage rates, what else did they
expect?

So what will happen to Pete. Will they foreclose on his pain meds? Will
the third party get a bail out? They spend a lot of money denying claims.
Maybe the Workmen's Comp companies ought to start lobbying for socialized
basic meds. There's still lots of room for supplemental insurance.

Damn, I have better things to do with my energy than fuss about this. Like
beading.

I decided to combine 2 things I don't like. Some heavy grey nylon thread
(heavier than the size 5 I have), and some weird size 6 beads in a sort of
amber, violet/peri, olive AB. So they will become another bead crochet bag,
along with some amber leaves, green flowers, a few brown leaves I have left,
etc. It will be uncharacteristically "organic".

Tina

Christina,

They cant deny payment of medication if they have approved the comp claim and have been paying for
the doctor visits, therapy visits, and meds. The TPA is only doing what the adjuster/carrier has
told it to do... and thats deny the payments of the medication or just plain deny auth for the meds.
The adjuster/carrier has ultimate financial control over the entire claim so what happens to the
claim is the adjusters fault.

What kind of doc prescribed the meds? Orthopaedic, pain management, Chiro? Well, most Chiro's are
not docs but you know what I mean. hehehe

If it was an Orthopaedic doc who prescribed the meds, then I would insist he get an IME (independent
medical evaluation) with a pain management doctor.

Has he had an FCE (functional capacity evaluation) yet? Has he reached MMI (maximum medical
improvement) yet? Has he been given a disability rating yet?

Does he had a nurse case manager assigned to the case and does he/she go with him for his doctor
visits?

I don't know where you guys live, and each state's comp laws are very different and also differ in
how claims process, but if you have not already done so - I would make sure your hubby files a claim
with your states work comp commission.

If you want more info on how to fight comp insurance carriers, send me an email:

Take the brackets { } off before you send


Sterling




"Christina Peterson" wrote in message ...
Pete was denied his meds by Workers' Comp, and the answers he's getting
reminds me of the variable rate housing crisis. It seems his employer paid
an insurer for Workmen's Comp. That insurer sends the claims to an
insurance adjuster. And the insurance adjuster has turned it over to Third
Party, or is it a third party, and they're saying his meds now cost too
much.

Of course, chronic pain gets worse, not better. And drugs lose their
potency. And new drugs cost more. So, yeah, I guess the costs to them have
increased. But like with the adjustable mortgage rates, what else did they
expect?

So what will happen to Pete. Will they foreclose on his pain meds? Will
the third party get a bail out? They spend a lot of money denying claims.
Maybe the Workmen's Comp companies ought to start lobbying for socialized
basic meds. There's still lots of room for supplemental insurance.

Damn, I have better things to do with my energy than fuss about this. Like
beading.

I decided to combine 2 things I don't like. Some heavy grey nylon thread
(heavier than the size 5 I have), and some weird size 6 beads in a sort of
amber, violet/peri, olive AB. So they will become another bead crochet bag,
along with some amber leaves, green flowers, a few brown leaves I have left,
etc. It will be uncharacteristically "organic".

Tina

opps, that addy is not working..... you can try petieis (at) cox.net




"Sterling" wrote in message news
Christina,

They cant deny payment of medication if they have approved the comp claim and have been paying for
the doctor visits, therapy visits, and meds. The TPA is only doing what the adjuster/carrier has
told it to do... and thats deny the payments of the medication or just plain deny auth for the
meds. The adjuster/carrier has ultimate financial control over the entire claim so what happens to
the claim is the adjusters fault.

What kind of doc prescribed the meds? Orthopaedic, pain management, Chiro? Well, most Chiro's are
not docs but you know what I mean. hehehe

If it was an Orthopaedic doc who prescribed the meds, then I would insist he get an IME
(independent medical evaluation) with a pain management doctor.

Has he had an FCE (functional capacity evaluation) yet? Has he reached MMI (maximum medical
improvement) yet? Has he been given a disability rating yet?

Does he had a nurse case manager assigned to the case and does he/she go with him for his doctor
visits?

I don't know where you guys live, and each state's comp laws are very different and also differ in
how claims process, but if you have not already done so - I would make sure your hubby files a
claim with your states work comp commission.

If you want more info on how to fight comp insurance carriers, send me an email:


Take the brackets { } off before you send


Sterling




"Christina Peterson" wrote in message ...
Pete was denied his meds by Workers' Comp, and the answers he's getting
reminds me of the variable rate housing crisis. It seems his employer paid
an insurer for Workmen's Comp. That insurer sends the claims to an
insurance adjuster. And the insurance adjuster has turned it over to Third
Party, or is it a third party, and they're saying his meds now cost too
much.

Of course, chronic pain gets worse, not better. And drugs lose their
potency. And new drugs cost more. So, yeah, I guess the costs to them have
increased. But like with the adjustable mortgage rates, what else did they
expect?

So what will happen to Pete. Will they foreclose on his pain meds? Will
the third party get a bail out? They spend a lot of money denying claims.
Maybe the Workmen's Comp companies ought to start lobbying for socialized
basic meds. There's still lots of room for supplemental insurance.

Damn, I have better things to do with my energy than fuss about this. Like
beading.

I decided to combine 2 things I don't like. Some heavy grey nylon thread
(heavier than the size 5 I have), and some weird size 6 beads in a sort of
amber, violet/peri, olive AB. So they will become another bead crochet bag,
along with some amber leaves, green flowers, a few brown leaves I have left,
etc. It will be uncharacteristically "organic".

Tina

We called the insurance adjuster, who told us that the meds were being
denied because the costs for them (new ones) were more expensive and the
Third Party people didn't count on them being so much. But she did go ahead
and authorize the meds. And asked Pete to call her Friday. So Pete now has
his meds. At least for this month.

Pete was originally injured in '91. After a bad snow storm he was sent from
here in Fairbanks to a place near Anchorage to clear electric line, to a
co-operating power company. He was told he could NOT use his own saw and
was given an extra heavy old one that had no vibration protection. He
worked 35-40 hours straight, and after that could not move his hands. The
next week he couldn't work, couldn't lift his arms. The doctor said they
could see no damage, but gave him various surgeries. He was off all that
summer.

(That winter his son was born, and weeks later his psycho wife left him).

Halfway through the following summer (he worked 7 months a years for 20
years) a job was created for him which was less physical, and paid the
allowable 60% of his original rate. He continued to have pain, surgeries,
loss of muscle control,etc.

Ten years later, a couple months after I married him, he fell at work and
re-injured himself. After trying to work for a week or two, he was no
longer able. He filed with Workmen's Comp. He was consistently told he had
nothing wrong with him, nothing showed up in X-rays, etc. He changed from
the orthopedic surgeon to a general practitioner of better quality, and
better listening skills. He was given a settlement of $30,000, and has not
been able to work since then. He was finally officially diagnosed with
Myofascial Syndrome/ Fibromyalgia several years ago. His related medical
costs are supposed to be paid for.

One of the big problems we have is that the forms are so difficult for us.
Pete was going through a divorce as well as pain with the first injury and
wasn't able to give it the attention it needed. In addition, Pete has a
disability that makes reading extremely difficult for him. With the second
injury, I was with Pete, but I have limited mental energy because of
Depression. (I don't get sad, my brain just gets tires). Brains also get
tired due to in people whose brains are bombarded with pain and new
unmanageable job and identity loss ("over-stimulation" is my psychologist's
description of Depression).

And you know, mentally ill people, people with Depression, which pretty much
includes all injured and traumatized people should not have to represent
themselves in negotiation with insurance lawyers. And because lawyers can
legally only receive 10% (as opposed to their standard 30%) in legal fees
when working on WC cases, none of them will take these cases on.

So we both have trouble keeping up the fight. Being constantly vigilant
doesn't work well for either of us. Even Kathy NV had trouble with having
to constantly re-prove her case, and she did everything right. We're just
trying to keep on keeping on.

The claim has been settled, so I don't know if more fighting is possible.
Though if they deny his meds maybe the case could be re-opened. At the time
of his re-injury it was not possible to sue the employer for injury due to
unsafe equipment thanks to new "conservative" pro-business legislation.

I wish we had had better resources to fight for a better settlement at the
time. Especially legal resources.

Thanks,

Tina


"Sterling" wrote in message
news
Christina,

They cant deny payment of medication if they have approved the comp claim
and have been paying for
the doctor visits, therapy visits, and meds. The TPA is only doing what
the adjuster/carrier has
told it to do... and thats deny the payments of the medication or just
plain deny auth for the meds.
The adjuster/carrier has ultimate financial control over the entire claim
so what happens to the
claim is the adjusters fault.

What kind of doc prescribed the meds? Orthopaedic, pain management,
Chiro? Well, most Chiro's are
not docs but you know what I mean. hehehe

If it was an Orthopaedic doc who prescribed the meds, then I would insist
he get an IME (independent
medical evaluation) with a pain management doctor.

Has he had an FCE (functional capacity evaluation) yet? Has he reached
MMI (maximum medical
improvement) yet? Has he been given a disability rating yet?

Does he had a nurse case manager assigned to the case and does he/she go
with him for his doctor
visits?

I don't know where you guys live, and each state's comp laws are very
different and also differ in
how claims process, but if you have not already done so - I would make
sure your hubby files a claim
with your states work comp commission.

If you want more info on how to fight comp insurance carriers, send me an
email:

Take the brackets { } off before you send


Sterling




"Christina Peterson" wrote in message
...
Pete was denied his meds by Workers' Comp, and the answers he's getting
reminds me of the variable rate housing crisis. It seems his employer
paid
an insurer for Workmen's Comp. That insurer sends the claims to an
insurance adjuster. And the insurance adjuster has turned it over to
Third
Party, or is it a third party, and they're saying his meds now cost too
much.

Of course, chronic pain gets worse, not better. And drugs lose their
potency. And new drugs cost more. So, yeah, I guess the costs to them
have
increased. But like with the adjustable mortgage rates, what else did
they
expect?

So what will happen to Pete. Will they foreclose on his pain meds?
Will
the third party get a bail out? They spend a lot of money denying
claims.
Maybe the Workmen's Comp companies ought to start lobbying for
socialized
basic meds. There's still lots of room for supplemental insurance.

Damn, I have better things to do with my energy than fuss about this.
Like
beading.

I decided to combine 2 things I don't like. Some heavy grey nylon
thread
(heavier than the size 5 I have), and some weird size 6 beads in a sort
of
amber, violet/peri, olive AB. So they will become another bead crochet
bag,
along with some amber leaves, green flowers, a few brown leaves I have
left,
etc. It will be uncharacteristically "organic".

Tina