“A good claim is a closed claim,” is a phrase often overheard in risk manager and claims adjuster circles. Employers, insurance carriers and other workers’ compensation payers tend to focus on settling claims, and phrases like this reinforce a one-dimensional view to settlement – as a way for the payer to eliminate financial exposure.
While this is true, to reach a settlement in workers’ compensation both parties are required to agree to a compromise so, on the other hand, what’s in it for the injured person? There need to be perceived or real benefits that outweigh the risk. A greater understanding on all sides of the potential benefits and pitfalls is crucial to inform how injured workers and their attorneys evaluate that trade-off.
At Ametros, we have found that when all parties involved in settlement discussions give thought to what the injured worker’s life will be like after settlement, it allows them to address concerns that the individual has which may be obstacles to settlement. These concerns can often be overcome with good planning and the help of a professional administrator to set up the injured worker for long-term success. With that in mind, perhaps another phrase to adopt would be that a “closed claim leads to a happier and healthier injured worker.”
Below are a few common concerns and how an administrator can convert them into potential benefits:
1. Although the injured worker may not like the workers’ compensation system, they have grown used to their support net and are scared to make a change. A nurse case manager or adjuster has helped them find providers, secured appointments, answered questions, and educated them on their treatment. Also, most haven’t had to pay (or even touch) any medical bills. Injured workers lose these resources after settlement and become responsible for managing their own care and paying for treatment from their settlement funds.
At Ametros, we find that about 32% of injured workers have had a significant change in treatment in the first 5 years since their settlement – a change in drug regimen or different type of therapy, etc.
Navigating healthcare alone can be a real concern for an injured worker. A professional administrator is equipped with a care team that can provide hands-on coordination and guidance to the injured worker. Just because the case has settled does not mean their journey to getting well is over. Having resources on hand after settlement can be a huge benefit for the injured individual.
2. Injured workers that are on Medicare or expected to be will likely have to deal with the reporting requirements of a Medicare Set-Aside (MSA). This means that for the rest of their life they need to make sure they are spending funds on Medicare-approved items related to their injury, using appropriate fee schedules and reporting their expenses in accordance with Medicare rules and regulations. This can be overwhelming. If they misuse or misreport their MSA funds and spend down the account, Medicare will refuse to cover future injury-related medical expenses.
At Ametros, we have observed that when MSA accounts fully run out of money, almost 100% of the time we receive a call from the Benefits Coordination and Recovery Center at Medicare to go over all the reporting.
Medicare is clearly paying attention and is issuing denials when they cannot track what happened. This could be a daunting call for an injured worker; a professional administrator can give them comfort that they will be prepared and ensures all this reporting is taken care of for them.
3. The thought of spending the settlement money too quickly is a common fear that most injured workers have. Medical inflation on certain items can be a scary unknown risk and can eat into the settlement funds. Also, new treatments that are more effective may be more costly as well.
Using a professional administrator that can provide medical bill, equipment and pharmacy discounts can help ease an injured worker’s mind by ensuring their funds will last as long as possible. At Ametros, our discount networks provide savings that keep more money in the accounts for future treatment. We find that less than 4% of our members run out of funds in a given year.
Jim’s Story
Each of the concerns above were becoming a reality for Jim, a former laborer and supervisor for a construction company in Indiana that had suffered a serious back injury. After settlement, he and his wife were watching his bills closely and were struggling with the cost of his medications, the coordination of his care and navigating Medicare’s guidelines.
Fearful of running out of money too soon, Jim even cut back on some treatments so that his money would last. The family turned to their attorney for advice and were directed to Ametros. The medical networks and pharmacy discounts in Ametros’ CareGuard program produced significant savings on Jim’s treatments. Now, Jim can afford to take all the medications he needs. He’s back on track with his treatment plan and is feeling better; knowing that Ametros’ care team is there for him, he is more confident in his recovery. He shares his experience in this video:
With CareGuard professional administration, Ametros sets up a custodial bank account for individuals who have settled their case, thereafter called “members.” Members receive a card that they present to their medical providers and pharmacies that enables the electronic direction of bills to Ametros. The company’s healthcare payment technology automatically verifies the bill’s accuracy, applies negotiated discounts to reduce the bill, and electronically pays the appropriate amount to the provider.
While every case is different, Ametros members enjoy savings that can range from 5% to over 50% on their expenses and the saved money stays in their account. CareGuard records all transactions and submits required reporting to Medicare for members with MSAs. Members have access to an online portal and mobile app to monitor their accounts and view expenses, savings and transactions so they always have transparency into their accounts without the hassle of handling the bills themselves. Plus, they don’t have to manage their care alone; Ametros’ Care Advocates are available to answer questions, help find providers, and sometimes just to listen.
Ametros is bringing patient advocacy to injured workers post-settlement, managing their medical issues so members can focus on regaining their health and enjoying their lives. All these benefits stack up and can, in turn, make injured workers more apt to settle their claim thereby creating more “good claims” in the eyes of risk managers but also creating more happy and healthy injured workers as well.
To learn more about Ametros and how we can help you, contact us!
*This article was originally featured on WorkCompWire.
