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Special Report: Workers' Compensation Appeals Board En Banc Clarifies Scope of WCJ Authority to Review Settlements

Posted by:  Sure S. Log
Topics: C&R Medical Evidence due process compromise and release disqualification judicial bias order suspending action LC 5001 settlement approval attorney fees en banc adequacy review OSA CCR 10700 stipulation

A workers' compensation compromise and release (C&R) agreement is not enforceable until approved by the Workers' Compensation Appeals Board (LC 5001). (For the purposes of this article, “the WCAB” refers to the Workers’ Compensation Appeals Board generally, including the workers’ compensation judge, and “appeals board” refers specifically to the appellate judicial tribunal within the WCAB.) Under CCR 10700, the WCAB is affirmatively required to inquire into the adequacy of all C&R agreements and may set a hearing to take evidence when necessary to determine whether a settlement should be approved or disapproved.

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Liability for Medicare Conditional Payments

Posted by:  Sure S. Log
Topics: C&R medicare medicare-set aside settlement conditional payment compromise and release

Medicare is a secondary payor. That is, it does not have primary payment responsibility for its beneficiaries when another entity is responsible for paying for medical care before Medicare. Workers' compensation is a primary payor for work-related illnesses or injuries. Medicare will not pay for a beneficiary's medical expenses when payment has been made or can reasonably be expected to be made by a workers' compensation insurer. Medicare, however, may pay for medical services when the primary payor has not made or cannot reasonably be expected to make payment for them promptly. Those Medicare payments are referred to as “conditional payments,” because Medicare pays under the condition that it is reimbursed when the beneficiary gets a workers' compensation settlement, judgment, award or other payment. Medicare is required by statute to seek reimbursement for conditional payments related to the settlement. The Centers for Medicare & Medicaid Services (CMS) has authority to look after...

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