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Workers' Compensation Blog

Are They Going to Stop My Pain Medicine?

Thursday, February 21, 2019

Current State of Affairs:

It is not a secret that there is an opioid crisis in this country. In recent months there has been a push by government to help cure this crisis. There are reports that pharmacies are in short supply of many opioid medications, and many doctors have refused to prescribe them at all anymore for fear of losing their medical license. There is no question that something has to be done, but the hope is that potential regulations and government referendums enact a holistic response to this epidemic. Sufferers need alternatives to pain pills and support to wean down from the addictive medicines.

Workers' Compensation and the Opioid Epidemic:

To an injured worker with extreme pain due to an accidental injury or an occupational disease the news can seem terrifying. Federal and state regulations seem to have taken an extreme attitude while examining doctors and dispensing pharmacies under a microscope. While regulations will have a beneficial impact on helping the crisis, the process in getting there may create greater hardship along the way. Many workers' compensation claimants do not know where to turn and are just waiting in fear that their medications will be cut off. Some insurance companies have stepped up and taken the problem head on. They have reviewed their client base and flagged those cases where the opioid level is very high and offered many kinds of treatment options to help a client manage their pain regimen.

However, other insurance companies are trying to cut medication doses that are not dangerously high and do not offer to pay for alternative treatments under the ‘guise' of helping the claimant get off their medications because they ‘care'. I have been in court too many times with issues of weaning off opioids, for the good of the claimant, and the insurance company is refusing to pay for alternative pain treatments or medications that are beneficial. This tactic goes against the very purpose that workers' compensation laws were enacted, but there is hope. The Workers' Compensation Commission understands that many injured workers' have severe injuries and will likely need to continue opioid use in lower dosages and will order alternative treatments and weaning programs in the appropriate circumstances.

What Should I Do if I am on Opioids?

The focus of late is to wean down not wean off and this should let injured workers' breathe a sigh of relief. Stopping narcotic medication ‘cold turkey' can cause grave implications on patients' organs as well as negative psychiatric effects due to the rapid increase in pain levels and withdrawal symptoms. Therefore, it is important to either participate in a proper weaning program or to work with your doctor to devise a safe and effective treatment plan. Without the proper support in place reducing these medications may feel impossible. The Center for Disease Control (CDC) categorizes a morphine equivalent dosage of opioids over 90mg as high and the recommendation is to wean down below 90mg.

The Workers' Compensation Commission has often ordered the insurance company to pay for alternative methods of pain management and outpatient weaning programs to support claimants' efforts in balancing an active lifestyle with lower levels of pain medications. The best thing to do is to talk to your pain management provider. Come up with a plan together to wean slowly down on your opioid use to find a manageable dose. Make sure that your pain management clinic is abiding by CDC guidelines in managing your opioid use and that your provider is communicating with your workers' compensation insurance provider so that you are receiving the authorization and approval for needed treatment. Many times insurance companies will deny benefits simply because the provider is not communicating the treatment plan with them or responding to inquiries.

Can I Choose My Own Pharmacy?

Thursday, February 14, 2019

If I can choose my own doctor can I choose my own pharmacy?

Several times a week we receive calls from clients that they are at their local pharmacy and their prescription was denied. This can often be the pharmacy that will not call the insurance adjuster, the insurance adjuster that does not respond or confusion over the mandatory waiting period to fill narcotic prescriptions. The result is frustration by all parties involved and an onslaught of misinformation ultimately resulting in the delay of much needed prescriptions.

What can I do to avoid this?

To alleviate this stress often clients will choose to use a mail order pharmacy. The mail order pharmacy usually takes the guess work out of why a prescription is denied. The mail order pharmacy is more likely to trouble shoot, call the adjuster directly and even reach out to doctors when a letter of medical necessity is required. Your local pharmacy may be too busy or overwhelmed to make all of these calls on your behalf. The downside is when you are filling opioids or narcotics such as oxycodone or oxycotin there are additional steps that may need to be taken.

With the many restrictions recently put in place to prevent opioid overdoses it may take an extra step or two depending on what medication you are taking. One of these restrictions is the requirement that the physical prescription must be sent to the pharmacy. These restricted medications are not permitted to be e-filed except in limited circumstances or with specific certifications. However, most mail order pharmacies have made it as easy as possible to alleviate the burden on the client. For example, they will provide UPS overnight envelopes to the doctor to overnight the prescription. Also, they recommend you see your doctor a few days before your refill is due and the doctor can post date the prescription, that way by the time the pharmacy receives the prescription it is on the day when the medication can be filled and the pharmacy will overnight the medication with no cost to you.

Can I choose my own pharmacy?

Over the past several years there have been frequent news worthy items regarding pharmaceutical contracts between insurance companies and pharmacies. These contracts allow a specific insurer to provide medications to the insured for less money if the specific pharmacy is used. Often the discount can be as great as 30% less the average wholesale price of the medication. Since the pharmacy is dealing on a very large scale they are able to provide this discount. Depending on the Insurance Company they will allow you to choose your pharmacy, but they will only pay out at the negotiated rate, very similar to doctor's taking the Maryland Workers' Compensation Rate.

While this issue is still being decided in the courts most insurance companies will payout at the charged rate by the pharmacy. It is best to find a mail order pharmacy that serves the Workers' Compensation community exclusively. Often they will forgive the amounts that the insurance company refuses to pay or that the commission will not award and always be aware that the pharmacy is not charging any additional filling fees.

Who Pays the Bill? Medicare or Workers’ Compensation?

Wednesday, October 31, 2018

Upon reaching the age of Medicare eligibility confusion abounds when determining if Medicare is the secondary or primary payer, especially if you have a prior workers’ compensation injury. Requirements have become more stringent on the workers’ compensation insurance companies to report claims to Medicare. As a result more recipients are receiving what is called conditional payment letters. A conditional payment from Medicare is a payment made even though it is another insurance company’s responsibility, of which they may seek reimbursement from the appropriate insurance company or the beneficiary.

Why does this happen and how will it affect you?

Primarily this occurs because it is easier for a provider to bill Medicare; all the systems are in place and they promptly pay their bills. Where the hospital is concerned Medicare might reject the claim as workers’ compensation related, even if there is no logical or medical connection to a prior workers’ compensation injury. In addition, once Medicare is notified that a workers’ compensation claim exists you may receive a letter in the mail from Medicare stating that they were notified that you have a workers’ compensation award. In the early stages this is purely an investigation by Medicare to determine if they paid for medical treatment that is actually the responsibility of the workers’ compensation insurance company. If Medicare determines through their own investigation that they have paid for treatment unnecessarily or made a conditional payment, they will seek reimbursement from the insurance company. Medicare may also sometimes seek reimbursement from the beneficiary and will notify them in the form of a conditional payment letter.

How do I know if it is a workers’ compensation related condition?

Another confusing situation is when you go to the doctor or hospital for what you thought was acid reflux, an unrelated condition, and it turns out you have hypertension, a related condition. Or when you go to the hospital for a heart condition, which is related, and the prognosis is instead an unrelated gastric condition. The priority is always to receive the medical treatment needed and then deal with who pays the bill afterward. It is imperative to retrieve all the medical records related to the condition and hospital stay from the hospital. These are documents that are specifically requested following your visit. This is not discharge paperwork, but the actual doctor notes and work-ups from your stay and/or visit. It is also helpful to ask your physician to comment specifically in the paperwork if in their medical opinion the condition is related to a prior workers’ compensation injury or it is unrelated. Finally, the notes should indicate the final determination of your diagnosis. Then, these documents can be used to help Medicare and your workers’ compensation insurance company determines the proper payer.

What do I do if I receive a letter from Medicare?

If a beneficiary receives a conditional payment letter it is important to respond in a timely manner indicating if it was in fact a workers’ compensation related medical expense and to include supporting documentation. Supporting documentation can come in many forms either as a denial letter from the workers’ compensation insurance company or commission, a letter from the beneficiary’s doctor, or medical records and a letter of explanation from the beneficiary. This process is another reason it is important to insure that a doctor’s office or hospital is billing the appropriate insurance company to save the beneficiary hours of work on the back end. However, the most important thing is to not panic. Remember it is a bureaucratic process that changes frequently and it is always a good idea to send a copy of the letter from Medicare to your attorney to review and to guide you in your response. If you are a previous client or current client with our firm we provide this service to you at no charge.

Why is it taking so long for my medical bills to be paid?

Wednesday, October 10, 2018

HCFA Forms

Maryland Workers’ Compensation laws require that medical bills be submitted on HCFA forms. These are standard billing forms used by most insurance companies that have fields for the appropriate and necessary CPT (current procedures terminology) codes. However, some practitioners may not be aware that this is a requirement for workers’ compensation claims or that the bill may be denied if it is not submitted properly on the HCFA form. The adherence to this rule varies between insurance companies, however if your provider is having trouble getting bills paid then the first step should be to ensure that the bills are submitted on HCFA forms. As an easy reference the workers’ compensation website provides a blank downloadable HCFA form.

Itemized Billing

Another reason your workers’ compensation medical bills are not getting paid could be that the bill that was sent to the insurance company was not itemized with the proper CPT codes. The workers’ compensation carrier cannot pay bills that are not properly itemized with these specific codes, similar to the codes that a primary care physician would provide to a private insurance company. In addition, many carriers also require that each office visit note from the billed dates of service are provided with the bill. This requirement is to ensure that the visit was related to a compensable body part or condition. Where the system fails is when the carrier denies payment of the medical bills and does not site to the reason it is denied. Often it is a clear case of one department not providing the proper medical records to the carrier’s billing department. Instead of working together the billing department denies the payment of the bill. To resolve this confusion and to save time our firm often will attach the appropriate medical report when sending in any reimbursement or bill pay request even though the carrier may have previously received the report.

Collections Letters

When a medical bill has not been paid, for various reasons, the provider will often send the bill to a collections agency or will seek payment from the claimant. It is important to know that a provider has their own course of action within the workers’ compensation commission to collect on bills for approved medical treatment. This is done through submitting a C51 claim for medical services to the commission. The commission will then issue an order nisi to the carrier requiring payment of the bills. The provider can request penalties, fees and interest if the bill is unpaid for over 45 days and the carrier failed to provide written communication of the denial. In addition, a claimant may notify the collections agency or doctor’s office that under Sec. 9-660, Labor and Employment Article, MD. Ann. Code, medical expenses related to an accepted and related workers’ compensation claim should be directed to the workers’ compensation insurance carrier.

Contact your Attorney

Facilitating payment of medical bills is one of the services we provide to our current and past clients for workers’ compensation cases we have handled. If you have not filed a claim for medical services that you feel are related to a workers’ compensation claim please contact our office as soon as possible so that we may assist you before these bills effect your credit.

Consequential Injuries May Be Covered Under Original Workers' Compensation Claim

Tuesday, February 06, 2018

Mr. M had a work related left leg injury.  He would go up and down the stairs using only his right leg.  He could only sleep on his right side.  He started using a cane on his right or “good” side to relieve the pressure and provide security against falls due to the imbalance his left leg injury had caused.  Then his left shoulder started causing him pain.  He had trouble buttoning his shirt and reaching for items in the kitchen cabinets.  Just my luck, he thought, now I have gone and done something to my shoulder.  After several months he was sitting with his lawyer discussing his workers’ compensation treatment for his left knee and he mentioned how it feels as if his body is falling apart.  After a few strategic questions from his lawyer and a visit with his doctor it was determined that the shoulder was related to his original workers’ compensation injury to his left leg.  The use of the cane caused additional pressure and strain on his shoulder.  Mr. M was able to have covered workers’ compensation treatment and an additional monetary award due to the shoulder strain.

When Will The Insurance Company Cover My Secondary Injury?

Similar to Mr. M many injured workers’ do not realize that if their secondary injury is causally related to the initial accident then that consequential injury may be compensable.  Consequential injuries are those injuries that occur directly as a result or consequence of an injury to a different body part.  For example, if a compensable knee buckles and causes a fall, which injures a wrist the wrist injury could then be deemed compensable.  It is important to document any of these consequential injuries whether at work or through a medical professional. Your attorney will work with you to gather the necessary medical documentation to prove that the injury is related to the original claim.  Then a hearing in front of the commission may be required to prove causal relationship between the secondary injury and the original injury.

Can I File For a Consequential Injury At Any Time?

Since there are statutes which impose limitations on when claims can be filed for additional injuries it is best to alert your attorney as soon as possible.  However, if the statute of limitations has run on earning additional compensation for the secondary injury it is still important to still talk to your doctor and your attorney about the injury.  Even if you are not entitled to additional money, you could be entitled to coverage for medical expenses and mileage related to your consequential injury.  It is always best to speak with your workers’ compensation attorney as soon as possible.  Many times in my practice clients only reveal the consequential injury after the statute of limitations has run or once it has become unduly burdensome, however if we handled your original claim I will handle your consequential injury even if no additional money can be earned.

The Importance of Documenting All of Your Injuries

Tuesday, July 18, 2017

All too often when workers are injured the focus is on the most severe parts of the body hurt. Frequently the minor pains and bruises from other parts of the body are ignored. However, in a workers’ compensation claim it is very important to report every hurt, bruised, or swollen body part no matter how minor it may seem at the time. The human body is interconnected and when you fall, for instance, you may land on your knee, but your hands may have eased the impact, which can cause shoulder and arm pain as well. If you injure your back, the nerve pain and/ or damage can cause problems in your legs. You may not feel any symptoms to those other areas until a day or two later, but these are all parts of your body that could get worse over time and require additional medical treatment. It is important in a workers’ compensation claim to document every part of the body that was affected by the accident no matter how small it may seem. It is more difficult to try and convince a Commissioner or insurance company that another body part was also injured in the same accident if there is no documentation of it within a few days of the accident.

What’s In The Injury Report Matters

This rule is important to remember when filling out your accident report at work, your workers’ compensation claim form, and any forms you are given at every medical office you visit after the accident. In our practice, we frequently read emergency room reports where an injured body part is left out or the wrong body part is documented. We all know hospitals are busy places and not everything is always documented with 100% accuracy, but insurance companies will use this to discredit your injury or the cause of your injury. It is important for you to check that how the accident occurred and that all injuries are clearly described and documented. Make sure to tell the medical professional you are dealing with every ache, pain and/or discomfort that you are feeling as a result of the accident.

Contact Us With Questions

If you have any questions about a new pain or problem that developed after your injury it is always best to contact an attorney. Our attorneys have years of experience and know the right questions to ask to ensure that you receive the full coverage, you are entitled to for your injuries.

I was told I have lifetime medical coverage, under workers' compensation, but they are denying my claim!

Friday, September 23, 2016

The Law. Many injured workers remember that towards the end of their case, when they settled, received a lump sum award, or weekly payments for a set period of time for their workers’ compensation claim, they were told that there right to medical treatment was left open for the duration of their life. However, of course, this comes with a caveat; according to the Workers’ Compensation Law of Maryland, injured workers are entitled to medical treatment with no time limitation, unless stipulated otherwise, for the body part that was injured at the time of the accident as long as the requested medical treatment is reasonable and necessary and is casually related to the original accidental injury.

What does this really mean? For continued medical treatment the injured worker must prove that their current need for medical treatment is still related to the original claim. Thus, the insurance company may not approve any treatment without a doctor’s letter stating that the current need for treatment is still related to the original claim. In my practice, clients often call me after two (2) - five (5) years of feeling fine and now have an onset of the same symptoms they felt several years ago from their accidental injury or disabling occupational disease. Injured workers are often frustrated that their employer’s insurance company will not automatically approve a visit or treatment. This is compounded when the injured worker finds out that before treatment is approved, the employer’s insurance company is allowed to send them to the insurance company’s own “independent” medical evaluation, which often times will state that the current need for treatment is no longer related to the claim. When there has been a large gap in time from the last date of treatment until the present need for treatment usually an injured worker must participate in a hearing to request the Commission to order the treatment or visit. Scheduling of these hearings can take several months.

What should I do? First the insurance company needs evidence through medical reports that the new symptoms are related to the original injury. Then the insurer will need to verify that the requested treatment is reasonable and necessary. Finally they will investigate to ensure there was no intervening event or accident that might have caused the onset of new symptoms. The best way to get your treatment as quickly as possible is to visit your doctor and ask them to write a letter that describes what treatment has been recommended, why the treatment is recommended and whether or not it relates back to the original Workers’ Compensation claim make sure all of your providers have your workers’ compensation insurance claim number and send reports and bills directly to the insurance company to ensure time is not lost in updating the workers’ compensation insurance file. In addition, verify that your attorney also has all of the appropriate recent medical reports, thereby supporting the effective and expeditious advocacy on your behalf. If Berman, Sobin, Gross, Feldman & Darby LLC was the law firm you used for the original claim we will continue to fight to get the medical treatment you need.

For More Information, Contact Attorney Julie Mirman 301-740-3306

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