THE QUICK SKIM
Short on time? This article delves into the ways a professional administration service can help your client manage their care after settlement including:
There are many pros for a client to settle their case including, less restrictive treatment, the freedom to see any doctor, provider, or specialist, and use any pharmacy. Settling allows an injured party to have more control over their treatment and focus on returning to health. On the contrary, once a client settles, they lose the support of being in the workers’ compensation system and may not realize how much they relied on these services. This is where attorneys have the power to change their client’s experience, help them get the care and resources they need after settlement, and reduce their liability.
Good attorneys representing clients who have workers' compensation and personal injury cases ensure they get the benefits and money they deserve. But what happens after the case settles? Are clients getting the same level of care? Do they have all the resources they need? Are they feeling empowered, or are they floundering? Perhaps most importantly: could you, as their attorney, be held liable if things do not go well post settlement?
After guiding a client through the process for months or years, attorneys wishing to avoid potential issues, want to make sure their clients are not left in the dark after settling. Far too often an injured individual's worst nightmare comes true after settlement: Clients can't find good providers nearby; they're confused about where and how to secure special equipment they need, so they go without; they run out of funds; and, worst of all, Medicare comes knocking at their door (and sometimes their former attorney’s door) because the Medicare Set Aside (MSA) account has not been properly managed.
This scenario can be avoided. Many plaintiff lawyers are heeding the advice of the Centers for Medicare and Medicaid Services (CMS) in partnering with professional administrators during the settlement process. Doing so gives injured individuals peace of mind and lessens the potential for attorney liability.
What Happens When There Are Problems After Settlement
Most stakeholders involved with injured individuals, including their attorneys, have only a vague idea of what an injured individual encounters after settling. Things change dramatically overnight - and sometimes not for the better. Problems arise when the support that was available before settlement vanishes afterwards. While the injured individual may be glad to be free of their respective workers’ compensation system, they most likely do not fully appreciate how dependent they were on the system and their attorney.
In addition to regular consulting with counsel, they also relied upon:
- A Claims Adjuster: While the adjuster might not speak to the injured individual often, they are at least someone who was thought to be a resource.
- A Nurse Case Manager: This person functions as a sounding board and facilitator for the injured individual’s medical needs.
- No out-of-pocket charges for medical coverage.
- Regular payments: Often, the injured individual’s indemnity payments are no longer paid.
Once the claim is settled, most support avenues disappear. Unfortunately, this is just the start of what could become a difficult adjustment for the injured individual.
Injured individuals who have settled a claim are now free to choose any medical provider they want. While that may seem ideal, the reality is that they are left to handle their own medical care. Additionally, the interplay of certain governmental regulations is daunting; especially if an MSA is involved.
A typical scenario for an injured individual who has settled their workers’ compensation, liability, or personal injury claim is the following:
They must find a physician who knows how to treat their condition. Without a nurse case manager or claims adjuster, the injured individual has no direction. Without any resources, the injured individual has difficulty determining and locating a good provider.
After their first visit with their new provider they are presented with a bill—typically, the usual and customary fee for the service provided. Once out of the system, there are no discounts and the injured individual is expected to remit full “sticker price.”
They secure medication by going to the nearest pharmacy to get their prescriptions filled. Again, they pay the usual and customary charge rather than the discounted price that was available to them previously.
The new treating physician recommends surgery to treat the injury. The injured individual is unsure who is available to speak with them about the procedure. They are free to have the surgery and pay for it out of their settlement proceeds, but they are unsure if it is a good idea.
A year after settling they begin to get concerned about their finances. The amount they received at the time of settlement seemed more than adequate. But their funds are being depleted just to cover basic medical and living expenses.
The injured individual becomes increasingly concerned as they hear and read about the MSA that was part of their settlement. Those concerns stem from a general lack of understanding, not knowing what is and what isn’t covered by the MSA or Medicare, not knowing how state fee schedules work, and not knowing their rights as it relates to considering Medicare’s interests.
Many times, the injured individual feels they were not given enough money in their settlement and they were not fully informed about what they would need to do to properly oversee and manage their MSA. Feeling scared, they’re not sure of their options so they call their attorney for help.
Having a professional administrator involved during and after the settlement completely changes the foregoing scenario.
"Professional administration has been a critical component in making sure my clients’ benefits are always protected after settlement. It brings peace of mind to both our clients and firm once the case closes and has proven to be an important and necessary resource for guidance after settlement."
- Brett Borah, Partner from Law Office of Borah & Shaffer
Professional Administration provides the following benefits:
- Medical Guidance: The professional administrator can act as a sounding board and, instead of directing the injured individual to a specific provider, they can discuss options and help in the decision-making process. Additionally, professional administrators usually have available durable medical equipment (DME) experts who can help the injured individual access any needed equipment—all at reduced prices.
- Financial Recommendations: Depending on the organization involved, the professional administrator can help the injured individual manage their funds earmarked for their medical needs. At Ametros, for example, we provide the injured individual a card similar to an insurance card that they use to pay for anything medically related. The professional administrator then deducts the payments from the injured individual’s designated account and maintains an up-to-date report of the fund that is easily accessible and reviewable by the injured individual.
- Medicare Compliance: A major challenge for injured individuals who settle their claims relates to the complex obligations that govern MSAs. MSA funds can only be used for treatment related to the specific injury and only those that would be covered by Medicare if it were responsible. There are other Medicare requirements, including annual reporting that must be submitted to CMS. Failure to comply puts the injured individual at risk of losing Medicare benefits if and when they need them. Professional administrators help with Medicare by handling the MSA in accordance with CMS directives to ensure compliance which protects the injured individual.
- Medical Discounts*: Once an injured individual has settled their case and is required to pay out of pocket for their medical needs, they typically pay full retail price for medical services and pharmaceuticals. Professional administrators typically work with a variety of providers and pharmacies and can offer significant discounts helping to preserve the injured individual’s settlement funds. With Ametros’ professional administration service, CareGuard, injured individuals save an average of 62% on provider bills, and 28% on all other medical expenses.
Many injured individuals who settle a workers’ compensation, liability, or personal injury case are not able to fully comprehend the scope of their obligations, and do not know what resources are available to assist them. Therefore, CMS now strongly recommends bringing in a professional administrator. CMS’ Wokers’ Compensation Medicare Set Aside Reference Guide states, “It is highly recommended that settlement recipients consider the use of a professional administrator for their funds.”
Just because an injured individual has settled their claim does not eliminate the need for professional guidance, direction, and advice associated with an injury. It is the responsibility of all those who care and have provided assistance to ensure that the injured individual has the resources to return to health and move on with their life.
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*Disclaimer: Any potential discounts or savings for medical treatment, including but not limited to, prescription drugs, durable medical equipment and/or healthcare items and services, are not guaranteed. Ametros has made no warranties, promises, representations or guarantees whatsoever about potential cost savings or the level of potential discounts obtained on any item, service or prescription payment. There are no assurances that prior successes or past results as to cost savings will be applicable to a Member on any of Ametros’ platforms. For additional information, please see our Terms & Conditions Page.