I stumbled across a news story out of Texas recently that surprised me a bit. It concerned a woman who had been denied treatment for her wrist by Medicare, because she had an open workers’ comp claim in the state. Even with all the talk and hullabaloo over Medicare and MSA’s the last few years, this specific problem was not one that I was aware of. 

Certainly we knew that there was potential for Medicare denial if the medical issue was directly related to the covered injury – that’s why we are immersed in MSA’s in the first place. But in this case the treatment Medicare denied was for a condition completely unrelated to the workers’ comp injury.

Esther Erwin was hurt on the job in 2001 by a broken cabinet, and needed stitches in her head. This year the problem was a swollen wrist; not related to work or her previous injury. Regardless of the lack of correlation, Medicare refused to pay her doctor. The reason? Erwin received a notice informing her that Medicare requires a letter stating that her workers' comp claim was closed. 

Her claim wasn’t. In Texas nobody’s claim is closed. Ever. In Texas the employee remains entitled to medical benefits for life so long as the treatment relates to the compensable injury. And Medicare was telling her it won’t pay any bill for someone with an open claim; apparently even if the treatment is for a non-compensable issue.

This clearly makes no sense. Not that I have come to expect common sense when it comes to Medicare issues, but still. I’m just sayin’….

So, I have a few questions related to this, and I invite readers far smarter than I (it is a short trip), and who may also be massively immersed in Medicare and MSA knowledge to impart their wisdom on this matter:

    1. Is this a common issue? In my limited realm of knowledge, Texas is the only state that does not facilitate the closing of claims in this manner. Is this something we see often in the state?
    2. Is there likely something not being included in this story, ie: the wrist was also injured and treated in the original work related incident but that information was excluded from the story?
    3. If this story is as presented, how do we fix it? Do we expect Texas to change their procedures? Or do we expect some common sense from CMS?

Ok, that last question seems a bit ludicrous. Clearly it will be easier for states to change their procedures completely than to ask for common sense out of the federal government. But this isn’t really Texas’ problem. This is the result of a technical policy decision at the federal level. 

This cannot be a simple medical coding error, as the letter did not indicate that they would not pay for a work related injury. Rather it stated the claim must be closed. So we are led to believe that this woman, and presumably others in similar situations, will be denied Medicare reimbursements if they have any prior claims in the state of Texas. Compensability be damned – open is open, after all. 

Seems pretty stupid on the face of things. What am I missing here?

Leave a Reply

Your email address will not be published. Required fields are marked *