Medicare Setaside problems

[lucky]

My PM Doctor for the last 6 years has decided he does not like my WC MSA Fee schedule payment even though he has accepted WC fee for the last 6 years. I believe he saw how much money I was given a year in my settlement and he wants more for his fee but I cannot do this; I am bound by the settlement and it says WC Fee sch. is to be the fee used which is common.

Can he drop me over his now disagreement with the WC Fee sch for his services?

This is GREED at its best. It puts me in a bad "pickle" because he is the only PM Doctor in a 150 mile radius. I really like him but this sudden change has me worried and pissed.

I was caught off guard with this today at my monthly appointment. GREEDY GREEDY GREEDY!

[1171]

yes in this respect a doctor is like any other business and is free to choose what payments they will accept.

PS. I don't think most set asides specify the work comp fee schedule.
you should look into changing the terms as it obviously reduces your choices and is little better then keeping your claim with the comp carrier and actually offers less protection then an open ended medical award.

I wonder how the comp schedule compares to medicare's?--once the set aside is exhausted you't be left with medicare only coverage.

[lucky]

(04-23-2012 08:06 PM)1171 Wrote:  yes in this respect a doctor is like any other business and is free to choose what payments they will accept.

PS. I don't think most set asides specify the work comp fee schedule.
you should look into changing the terms as it obviously reduces your choices and is little better then keeping your claim with the comp carrier and actually offers less protection then an open ended medical award.

I wonder how the comp schedule compares to medicare's?--once the set aside is exhausted you't be left with medicare only coverage.

Most Medicare Setasides per my Attorney use the Workers Comp fee schedule when a life care plan is built for a Medicare Setaside.

Everyone I know who has a MSA settlement is based on WC Fee schedule.
There is no changing as this is a C&R settlement.

In Louisiana,settling with open medical will not happen. I asked for this and the IC would not have it. The IC wants the IW released totally. NOW, some states have open medical as the option... Also I would prefer to not have WC in my life anymore and they would be with open medical.

I have friends in Illinois and Florida who settled with a C&R like me with a Medicare setaside and both are built around there states WC fee schedule. It is common to do this.

Medicare pays less; I know this by looking at the Diagnostic code which is the same code for WC and Medicare and also private insurance. This is a universal diagnostic code.

---

This is from CMS website.

Use of WC Fee Schedule vs. Actual Charges for WC Medicare Set-aside Arrangement
(Ref: 10/15/04 Memo Q1)

The CMS uses either the WC fee schedule (for states that have such schedules) or the full actual charges for its review of a proposed WCMSA based upon whichever methodology is used by the individual/entity submitting the proposal. The administrator of the WCMSA (both professional administrators and self administrators) should make payments from the WCMSA on the same basis. That is, if the proposal was submitted and approved based upon full actual charges, the administrator should make payment from the WCMSA based upon full actual charges; if the proposal was submitted and approved based upon WC fee schedule amounts, the administrator should make payment from the WCMSA based upon WC fee schedule amounts.

The CMS reviews WCMSAs on a case by-case basis in order to determine whether Medicare has an obligation for services provided after the settlement that originally were the responsibility of WC. Accordingly, in reviewing a WCMSA, CMS must know whether the arrangement is based upon WC fee schedule amounts or full actual charge amounts. (Ref: 7/23/01 Memo Q5 Note).

[1171]

there are many states yet that don't have mandatory fee schedules.
for the couple of states that I have worked with that do have fee schedules (california & arizona) they have stipulated in the MSA to full actual charges.

what would happen if you moved out of state?
most doctors would not accept another states fee shedule.
you would be confined to only to treatment in your state. bizarre.
would the set aside pay for transportation and living expense as you traveled back and forth?

so I guess you would have to subsidize the addition fee for comp treatment.

[lucky]

(04-24-2012 01:24 AM)1171 Wrote:  there are many states yet that don't have mandatory fee schedules.
for the couple of states that I have worked with that do have fee schedules (california & arizona) they have stipulated in the MSA to full actual charges.

what would happen if you moved out of state?
most doctors would not accept another states fee shedule.
you would be confined to only to treatment in your state. bizarre.
would the set aside pay for transportation and living expense as you traveled back and forth?

so I guess you would have to subsidize the addition fee for comp treatment.

One of my friends moved to Florida from Illinois; They accepted his WC Fee from Illinois from his MSA which was actually more than Florida. Now, If he moved from Florida to Illinois it would suck but that is part of settling.

The setaside does not pay for any traveling expenses. Unless the state the IW resides in requires it, No IC will settle with open medical; They want the books close.

I wish Louisiana had the stipulation of Actual full charges but they do not. I spent over 3 years trying to settle after MMI; We finally came to a good agreement. I should be fine except for this scenerio above.

There is no perfect settlement; The IW will have to "give" to settle.

[AQA]

Lucky,

One correction to what your said. "The setaside does not pay for any traveling expenses. Unless the state the IW resides in requires it, No IC will settle with open medical; They want the books close".

The above part of your post is incorrect. I have medical coverage for the injury until I die. I see two different drs. every ninety days and my meds are also covered. My SCS id due to fail in a year and the IC will be responsible for the replacement.

I hope that you don't think I am nit picking or being a prick. I just don't want others that may come after we are gone to read the post and think they can not get open medical. Most will have to fight to get it, but it does happen.

Take Care

[PainandSmiles]

How would your doc see how much money you are getting? I assume that's between your lawyer, the IC, you and whoever you've told?

[jayne]

wondered that myself.....sure your not being a bit paranoid?