By Michael Stack, Principal of Amaxx Risk Solutions
Imagine a scenario where an injured worker, who’s been receiving workers’ compensation benefits for years and has shown no interest in settling, is suddenly willing and even happy to do so, and both he and the payer are pleased with the agreement. The payer gets the long-term claim off the books, and the injured worker has someone guiding him through the medical system while helping to manage his money long after the settlement is reached. Both parties save money in the process.
This panacea is not only possible, it is happening. Professional administration is enabling an increasing number of settlements to occur and leaving all parties feeling grateful with the results. Professional administration organizations that have a solid background in all aspects of workers’ compensation are becoming the answer to the frustrations faced by long term injured workers.
The concept of professional administration is not necessarily new in the workers’ compensation industry, but until recently it was generally cost prohibitive for many organizations. Recently that has changed, as newer entrants have found ways to save money for all concerned.
The way it now works is simple and effective:
- Those with the appropriate competence are able to offer significant discounts to injured workers through their networks of medical providers and pharmacies
- They function much as an engaged claims adjuster would in terms of helping the injured worker find the best providers
- However, the injured worker’s care is not subject to utilization review
- The professional administrator also helps the injured worker manage their settlement money, whether lump sum or structured, and can ensure injured workers receiving Medicare are compliant with government reporting requirements
Professional administration can work well for any injured worker with a long-standing claim but is especially advantageous for those exasperated with the system;
- The person who has been on comp for months or years and is constantly trying to get medical care that is ultimately denied by UR.
- Among her frustrations is that she has to drive many miles from her home to see an approved physician – whom she may not like. With professional administration, there is the freedom to see any doctor or provider.
- She may have already settled the indemnity portion of her claim, meaning her attorney has likely abandoned any thought of helping her get the medical care she still needs.
- As much as she dislikes and distrusts the workers’ compensation system, the idea of settling the medical portion of her claim makes her even more anxious, as she is afraid she will ultimately run out of money.
Such stories are fairly commonplace in the workers’ compensation system. Injured workers who have been in the system for a long time are afraid of the unknown, post-settlement scenario and are therefore willing to put up with keeping their claim open.
Professional administrators can be invaluable in helping to reach a settlement and providing support after the agreement is set.
Among the many concerns of long term injured workers facing a potential settlement are the financial unknowns; how much will various treatments and medications cost, now and in the future? What if unexpected complications arise – will there be enough money to treat them? What if durable medical equipment becomes necessary – is there enough for that? Is the settlement money enough to ensure living expenses can be covered for the long term? Who should manage the money?
More concerns are present when the injured worker is receiving Medicare:
- What medical services should be funded through Medicare?
- What if Medicare is mistakenly billed for a treatment the injured worker should have covered?
- How, when and where are the Medicare reporting requirements handled?
- What if they are reported improperly?
It’s easy to see why many injured workers would be leery of settling their workers’ compensation claims and having to answer these questions on their own. A professional administrator can price out the prescriptions and treatments and show the injured worker an accurate picture of the costs, especially when network discounts are included. Competent organizations get involved with all parties to the claim before a settlement to reach the best solution for all concerned.
Typically, there is no help for an injured worker after a settlement is reached. Those with extensive and expensive medical needs and/or those not comfortable managing the settlement money feel lost.
- With a professional administrator involved, the injured worker has full control over choice of providers, and an expert helping to manage the settlement funds.
- In addition to discounts for medications and providers in the network, there may be a 24-hour/7-day-a-week phone line available to discuss care issues.
Because of the savings associated with a professional administrator, injured workers often have money saved away to fund future needs of their family: their grandchild’s education, starting new businesses, or taking exciting trips. Above all, they have peace of mind about the future.