October 4, 2023 • Education

Closing Future Medical Claims: Keep it Simple to Get to Settlement

Table of Contents

Settling a workers’ compensation or liability claim can be a win-win for injured individuals as well as others involved in the future medical case. But the process to get there can be complex.

Many moving parts can lead to delays or even the decision to cancel the settlement. In addition to the injured individual, professionals involved may also be uninformed about the many nuances.

The key to an optimal settlement is simplifying the process for all involved. Armed with the right knowledge, the parties can come to the table with a clear vision. But simplifying the settlement course takes vast experience and a deep understanding of the many facets at play. Although, there are both opportunities and potential challenges an individual may face when settling their future medical, fortunately, there are experts who can turn what could be an enormously complicated process into a smooth path, leading to a positive outcome. Let’s further examine some of the positive changes an individual can experience upon settling their future medical and some of the areas where an expert resource like professional administration can help simplify continuation of care moving forward.

Settlement Pros

Settling a claim can be a freeing experience for the injured individual. It eliminates the restrictions inherent in the workers’ compensation system. Among the changes are:

  • More treatment options. An injured individual who has settled his claim is free to see any provider or use any pharmacy he chooses. While the workers’ compensation system requires approval for medical treatments and medications, there are no such restrictions post-settlement. That may mean the difference between having to travel long distances to see a specific provider and the ability to see a physician close to home.
  • A new start. Many injured individuals who have reached a positive settlement outcome report a sense of moving on with their lives in leaving the workers’ compensation system behind. Independent medical exams or court appearances, for example, are no longer required.
  • A change in responsibility. The injured individual is now in control of their own health care, free of the requirements of the workers’ compensation system.

...and Potential Challenges

But the newfound freedom may also bring unwelcome changes to the injured individual. These are the reasons the person may decide against settling their case.

  • Lack of support. Claims adjusters, nurse case managers, attorneys and others may be instrumental in helping the injured individual who is in the workers’ compensation system. Settlement means all those in the support system are gone, leaving the person on his own to navigate his health care needs. Simple questions that would be easily answered may become anxiety-producing situations. Coordinating care, once the responsibility of someone else, is suddenly thrust on the injured individual.
  • Loss of Network Discounts. Injured individuals get their medical needs paid through the workers’ compensation system. The employer and/or insurer can provide this through its volume discount networks for providers, pharmacies, and other medical treatments. Once a settlement is executed, the injured individual is faced with paying retail for these services. Injured individuals who believe their settlements are adequate to provide lifetime benefits may face sudden sticker shock – and the realization that the money may not last.  
  • Medicare Requirements. Keeping up with and adhering to the requirements for Medicare is a must, lest the injured individual risk having his future Medicare benefits denied. Once the claim is settled, this is the sole responsibility of the injured individual.

Upon realizing the potentially negative consequences of post-settlement life, injured individuals often opt to stay in the workers’ compensation system rather than settle. But this does not need to be the outcome. Professional administration experts like Ametros are available to guide the injured individual and other professionals before, during, and after the settlement.

How Ametros simplifies the settlement process for injured individuals and insurance professionals.

Professional Administrators

“It is highly recommended that settlement recipients consider the use of a professional administrator for their funds.” This advice from the agency that oversees Medicare is a realization that managing medical funds post-settlement is no easy task.

Some professional administrators also go the extra mile and ensure all parties to a settlement understand the steps and what to expect throughout the process. These advanced organizations can simplify the process.

For injured individuals, it means:

  • Simplifying the settlement process during and after the settlement
  • Simplifying the complexity of healthcare, such as medical billing, and helping understand state fee schedules
  • Educating on the complexities of MSA administration as part of the settlement process
  • Removing the burden of CMS reporting with a team of compliance experts

For professionals, such as claims managers and plaintiff and defense attorneys, it means:

  • Bridging the gap between parties during settlement, such as attending mediations and conference calls
  • Providing a resource to clarify common objections or answer any questions from the individual that may be roadblocks to settlement
  • Simplifying the complexities of MSA Administration guidance

Simplifying Settlement for Individuals

Most injured individuals approach the idea of settling their claims with enthusiasm and optimism, believing they can leave the workers' compensation system with financial freedom to enjoy their lives and pay their medical bills. This outlook is, unfortunately, all too often quickly abandoned.

The steps involved in the settlement, the complications, the documentation required, and the very process to determine what is adequate to fulfill their needs is certainly not always straightforward. It is tedious and must be carefully created to determine a settlement that addresses the injured individual’s need and is fair to the employer/insurer. Simplifying this means working closely with the injured worker each step of the way, especially before the settlement, so there are no unwelcome surprises.

Simplifying the Settlement Process: A Helping Hand Throughout

Navigating the intricacies of the settlement process can be a daunting task. Fortunately, professional administrators understand the nuances of this journey and streamline the settlement process from start to finish. A major concern of many injured individuals – losing their support teams – is addressed through best-in-class professional administrators who provide full-service support throughout the injured individual’s lifetime. While many injured workers periodically call the professional administrator with basic questions, those with more complex injuries may need more care and continuous support. From custom support during and after settlement to ensure a seamless transition of care to ensuring all parties involved fully comprehend the steps ahead and what to expect, administrators provide peace of mind when it's needed most.

Simplifying the Complexity of Healthcare: From Billing to Coding

Healthcare can often resemble a labyrinth, with its intricate medical billing procedures and perplexing diagnostic coding. Professional administrators have honed their expertise in this domain, armed with the knowledge and experience to simplify even the most convoluted aspects of healthcare.

Paying out of pocket – or paying out of settlement – for medical care is complex and must be done with care. To ensure an individual isn’t paying self-pay rates and for items unrelated to their injury, professional administrators ensure accurate diagnosis coding and provide potential provider network savings for physicians, medications, and treatments, that would otherwise be unavailable without professional administration. From decoding medical bills to ensuring proper payments, administrators serve as valuable allies, enlightening injured individuals on the intricacies of their medical care and their specific settlement documentation.

Mastering MSA Administration: Educating for a Seamless Settlement

Within the settlement process, the complexities of Medicare Set-Aside (MSA) administration can leave many feeling bewildered and overwhelmed. This is where professional administrators step in as educators, sharing their wealth of knowledge to ensure injured individuals fully comprehend the nuances of MSA administration. An administrator will be able to educate an individual on CMS’ guidelines for MSA administration in the context of their unique settlement and handle all the administrative requirements on the individual’s behalf.   By demystifying the intricate details and providing clear explanations, these administrators empower settlement recipients to make informed decisions, paving the way for a seamless settlement journey.

Relieving the Burden of CMS Reporting: Compliance Experts to the Rescue

Medicare Set-Asides often used to satisfy Medicare’s secondary payor status, have a plethora of requirements to ensure Medicare does not pay for injuries that are not its responsibility. Among them are:

  1. The funds must be held in an interest-bearing account
  2. The funds may only be used for treatments related to the injury
  3. The funds may only be used for Medicare-covered expenses
  4. The funds must be paid according to the appropriate fee schedule
  5. The injured individual must prepare and submit an annual accounting report to Medicare
  6. The injured individual must maintain line item detail for the duration of eligibility

However, professional administrators come to the rescue with their team of compliance experts. By having Medicare Set Aside funds professionally administered, injured individuals can bid farewell to the burdensome task of CMS annual attestation reporting. Instead, they can rest assured that a dedicated team will handle all compliance-related matters, ensuring seamless communication with Medicare and alleviating the stress associated with reporting obligations.

Simplifying Settlement for Professionals

The best and easiest way to get a case closed is to provide high-level, accurate guidance to the injured individual. Claims managers, attorneys, and others are experts on various issues and cannot be expected to excel in every area of the nuanced world of claim settlements. Some professional administrators have created resources and specialized support teams to help these professionals achieve future medical claim settlements with successful outcomes.

Bridging the Gap: Enhancing Communication and Collaboration

One of the roadblocks to settlement occurs when the various parties involved cannot agree on essential elements. While the professional administrator’s job is first and foremost to help the injured individual, mediating among the various parties can enhance and improve the process.

Effective communication and collaboration between parties are crucial for reaching mutually beneficial outcomes. Best in class administrators may have designated representatives that excel at bridging the gap between all involved parties, providing a crucial link that facilitates conversations for smooth negotiations. From attending mediations to participating in conference calls, these administrators ensure that everyone's voice is heard, conflicts are resolved, and agreements can be reached. By bringing clarity, efficiency, and a neutral perspective to the table, professional administrators foster an environment of collaboration, propelling settlements forward.

A Valuable Resource: Overcoming Roadblocks and Answering Objections

Settlements can hit roadblocks due to common objections or unanswered questions, hindering progress and frustrating both the injured individual and workers' compensation professionals. Professional administrators serve as a valuable resource in these situations, providing the expertise needed to overcome obstacles and address concerns about future medical settlements. These administrators act as a guiding light, helping workers' compensation professionals clarify objections and provide clear answers to any questions that arise. With their knowledge and experience, professional administrators empower professionals to navigate potential roadblocks, paving the way for successful settlements.

Simplifying MSA Administration: Expert Guidance Made Easy

The complexities surrounding MSA administration can be overwhelming, posing challenges for workers' compensation professionals striving for seamless settlements. Enter professional administrators, armed with the expertise to simplify the intricacies of MSA administration guidance.

Many professionals have a basic understanding of Medicare and MSAs. However, without in-depth knowledge and understanding, they may not be able to provide information about the complexities of MSA administration. A professional administrator’s role during settlement can include simplifying the process and educating on MSA administration guidelines to enable professionals to help the injured individual. By providing a simplified roadmap, administrators empower workers' compensation professionals to navigate MSA administration with confidence and ease, saving time and minimizing potential pitfalls during settlement.


‘Keep it simple’ is an adage often used in business and the military to address complex situations. In the case of settling future medical claims, it can mean the difference between long-term cases and closed cases. Relying on a highly qualified professional administrator can be the key.

Reach out to our team!