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Managing Medical Care After Settlement: Are Injured Workers Up to the Challenge?

Do you think you would get fair prices if you had to pay for each of your healthcare expenses out-of-pocket?

Each year, tens of thousands of injured workers decide to settle their cases. This means, each year tens of thousands of individuals that experienced a life-changing injury receive cash settlements for their future medical expenses, ranging from a few thousand dollars to millions.  The injured workers then pay out-of-pocket for treatments related to their injury, relying upon their individual knowledge of healthcare and sometimes a complex fee schedule and medical bill review rules provided by the state.

Injured workers that settle their claim have the opportunity to take control of their medical care without interference from an insurance carrier, self-insured employer, or third party administrator (collectively, “payors”) that may have been managing their case pre-settlement. The settlement itself can represent another life-changing event for injured workers because they may receive significant sums of money for future medical care for which they alone are now responsible and must control.

When injured workers decide to settle their future medical, they receive valuable cash settlements and freedom to treat as desired. However, rarely do professionals in the industry or the injured workers themselves at the settlement table recognize what the injured workers are leaving behind: the structural cost saving and medical management benefits of the workers’ compensation system provided by the payor. After settlement, injured workers no longer have access to the payor’s preferential pharmaceutical or provider rates, sophisticated systems to negotiate and manage their bills, or a third party advocate supporting their health care treatment needs.  Instead, injured workers face many obstacles, including managing their care, making sure they do not exhaust their medical settlement funds, and, in light of recent enforcement, complying with Medicare Set-Aside reporting requirements and other federal regulations.

For example, I challenge you, to survey the next injured worker you encounter.  Ask them not only if they know what their state’s fee schedule is for workers’ compensation, but also where to find it and how to interpret it.

Similarly, I challenge all of us professionals, who either work in the workers’ compensation industry or in related fields, to do the same.  I assure you, the task is not easy.  And it is what we ask of injured individuals who often have few resources or knowledge of the system at their disposal.

The end result is that, in most instances, when injured workers are left on their own after settlement, they fail to manage their care appropriately.  They overpay for treatments and drugs, depleting their funds more rapidly than expected.  They lose track of bills and fail to comply with regulations putting their Medicare and other benefits at risk. Post-settlement, injured workers are essentially operating without support or assistance in a complex medical system when many of those injured workers have more healthcare needs than the average individual in our society.

Many people underestimate the resources payors use, pre-settlement, to manage injured workers’ medical care.  While there may be disagreements on utilization review, acceptance of the injury for certain body parts, what providers to utilize, or other conflicts, it is clear that payors have expended significant resources in developing sophisticated systems and establishing partnerships to reduce the cost of medical bills and to coordinate and track medical care.  In many circumstances, the payor has negotiated favorable pricing with pharmacy partners, provider networks, and medical equipment vendors. The payor or plaintiff attorney may even help the injured worker find a provider, coordinate provider visits and schedule appointments. While many of these services are meant to help the payor save money and control costs, they also are often immensely helpful to the injured worker.

However, the injured worker does not have to leave all of these efficiencies behind when they settle their case. These same beneficial services can also be accessed by the injured worker after settlement through customized professional administration services that cater directly to the injured worker and their needs.

Professional administration is a vastly under-utilized service that significantly assists an injured worker post-settlement. Professional administration of future medical is a service that provides the injured worker with the resources and support that they previously had through their payor, but in a more streamlined manner.

For example, with professional administration, there is no utilization review or the requirement to use a medical provider network (MPN); instead, the injured workers can treat as frequently as their doctor sees fit and with any provider they would like, providing injured workers with freedom to treat with the added support to help them maximize their medical care.  Professional administration services provide access to discounted drug, provider, and medical equipment pricing; access to technology that provides a hassle free experience with medical care; and access to a dedicated team of representatives to answer questions and help the injured worker navigate their medical care.

Despite the many challenges an injured worker may face after settlement, it is estimated that less than 5% of injured workers actually take advantage of professional administration services.  This means, that of the many injured workers that settle their case each year, the vast majority are currently attempting to manage their care without customized services that would otherwise allow them to save money and manage their medical care more efficiently.

Professional administration services can save injured workers as much as 40% off of average wholesale drug pricing, in addition to further savings of up to 60% off provider and hospital bills by reducing bills to their proper fee schedule rate (or lower) through proactive negotiation.

As professional administration services have become more popular, for the first time, there is actual data and insight into what happens to the injured worker and their medical funds after settlement. Attorneys have indicated that they no longer take as many telephone calls from their clients after settlement because their clients rely upon the healthcare experts at the professional administration company to address their concerns. There has also been positive feedback from many injured workers about the impact that professional administration has had on their lives and the ability to extend their medical funds.

The workers’ compensation system was built to protect injured workers. Significant work and resources are dedicated to ensuring the system runs well. However, the system was not designed to care for injured workers who have settled their case and exited the system.   Professional administration can help alleviate injured worker’s concerns about exiting the system and thereby help get the case settled.  It is a tool that can help plaintiffs’ attorneys position their clients for post-settlement success.  Most importantly, it is a tool to help the injured worker.

Over the past decade, professional administration companies have emerged as an affordable and practical solution making significant strides in driving savings for injured workers and increasing the ease of gaining access to medical care.  In most cases, at CareGuard, we find that we save the injured worker over 5x the cost of the professional administration services.

For many injured workers, after settlement, the real work is just beginning.  For cases big or small, are injured workers prepared and equipped to handle their future medical expenses on their own?

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