March 28, 2016 • Ametros UpdatesEducation

A New Tool for Settling Open Medical Claims: Professional Administration

The almighty dollar is often just one component of a successful workers compensation settlement.  Savvy negotiators recognize that they have several tools at their disposal when it comes to bridging the gap between the payer’s offer and the plaintiff’s demand, many of which dictate how and when the settlement dollars can be used. gavel On both sides of the negotiating table, many are adept at minimizing or maximizing the medical cost projection or the amount that goes into a Medicare Set Aside (MSA).  Many in the industry also understand how a structured settlement (annuity) can unlock value and allow for the pacing of stable income for the claimant. Now, a small but growing number in the industry are beginning to understand how offering professional administration (PA) of the claimant’s future medical funds can help facilitate a settlement.  PA provides the claimant with a dedicated support team after they settle their case, along with technology to ensure they save money when they actually spend their settlement dollars on healthcare purchases. What settlement issues can you use PA to address?  The most often cited concerns of injured workers when they face the prospect of settling are regarding 1) access to their medical treatment and 2) how long it takes to get a response from their adjuster, attorneys or the board as they go through settlement process.  Examples of these concerns are easily found by reading the comments directly from injured workers in a survey conducted by the New York Worker’s Compensation Board.1  Issues like “denied treatment” and “delayed processes” are at the core of nearly every complaint.  PA is effective in addressing these concerns because PA services do not restrict the claimant’s access to medical treatment via utilization review or a MPN; on the other hand, they facilitate it by providing more options of providers and expanded choices for treatment of their medical condition.  In addition, many PA services have call centers that offer ongoing support to their clients, the injured worker.  CareGuard, for instance, offers 24/7 coverage to its members and prospective members to answer any questions they may have as they navigate the complex healthcare maze after settlement. Through the life of their claim, many injured workers simply lose trust in the attorneys, judges or system in general.  This is often because the settlement process sets the parties up at a table for purposes of a one-time transaction, but then each group walks their own separate way.  There is sparing research done on injured workers’ attitudes toward settling their case, but a survey in Minnesota in 2013 scratched the surface of what a daunting undertaking settling is for the injured individual.2  The study found that about one third (1/3) of injured workers did not fully understand their settlement.  Further, it revealed that around three quarters (3/4) of injured workers did NOT believe they achieved a “fair” settlement.  The sample used were folks who actually overcame their concerns and settled regardless of the negative sentiment the process evoked.  Many claimants do not have the courage to push forward with settlement and instead decide to leave their future medical claim, if not their entire claim, open. PA can be a valuable tool, whether for adjusters, defense attorneys or plaintiff attorneys alike to inject trust and solutions into a contentious situation.  By engaging a PA company, a team becomes available to address the claimant’s concerns about their future medical treatment.  It also introduces a party to the settlement negotiation whose interests are aligned with the claimant’s since the PA provider will be the only party continuing to provide ongoing service to the claimant after settlement. This can give the claimant much needed peace of mind that it has a partner looking out for their best interests, and it is this peace of mind that helps reluctant claimants see that settling could in fact be their best decision. PA services give claimants comfort and confidence that life after settlement can be a rewarding and hassle free experience. How can you leverage PA in a settlement? To leverage PA effectively, negotiators on either side of the table should introduce the service early on in the process and clearly explain its benefits to the claimant.  Often times it’s useful to connect the PA provider directly with the claimant and/or their attorney so that a relationship is established and the service is well understood.  After all, the agreement between the PA provider and the claimant will exist for years beyond the settlement; it’s better to begin that relationship early on rather than try to throw it in last minute. The PA provider can serve as a neutral party that helps explain to the claimant what they can expect after settlement.  Some PA providers, like CareGuard, can go further to provide cost analyses of what treatments will cost on their platform and demos of how their service works.  PA providers understand that they do not get paid until the case settles, so they are a source of information and guidance toward settlement for all parties involved. Questions? Contact Us! Sources: 
  1. New York State Worker’s Compensation Board Business Process Re-engineering “Comments from Injured Workers Survey,” 11/1/13 – 3/19/14.
  2. Minnesota Department of Labor & Industry “Workers’ Perspectives on Settlements and Hearings,” 2013.

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