The Ametros home office will be closed Christmas Eve (After 3PM EST) and Christmas Day (All Day)

FAQs


Ametros Company FAQs →

Workers' Compensation

What is workers’ compensation?

Workers’ compensation is a no-fault benefit system established by state governments to provide coverage for employees injured at work. It ensures that employers offer required compensation coverage to their employees. The system's fundamental test for work-related claims is whether the injury occurred at work and because of the job.

Key Features of Workers’ Compensation

  • Coverage Scope
    • Provides both indemnity benefits, which replace lost wages, and medical benefits, covering necessary medical care due to the work injury.
    • Indemnity benefits are tax-free and typically calculated as a percentage of the injured worker’s average weekly wage.
    • Medical benefits extend to hospital, doctor, pharmacy, and related expenses.
  • Employee Eligibility
    • Exclusively applies to employees; independent contractors and sub-contractors are not covered.
  • State Specifications
    • Each state’s workers’ compensation system has unique requirements, which are accessible via its respective website.

Special Provisions for Occupational Diseases

Initially designed for injury events, the system now includes provisions for injuries due to harmful exposures, such as chemicals, through Occupational Disease Acts. This legislative extension protects workers from hazards like black lung or asbestos exposure.

Historical Background of Workers' Compensation

During the early 1900s, workers injured on the job had limited recourse, often suing employers or co-workers for compensation. The lack of employer insurance often rendered judgments ineffective, risking business bankruptcy and causing strained relations. The modern no-fault system traces its roots to Germany's early 20th-century ideas. Wisconsin enacted the first U.S. Workers’ Compensation Act in 1911, prompting other states to follow. Mississippi was the last state to make it mandatory, with Texas remaining the only state where coverage is optional, although most employers choose to participate.

For more information, you can consult your state's workers' compensation website to understand specific state requirements and provisions.

Can I sue my employer for a work injury?

Workers’ compensation laws generally protect employers from being sued by employees for work-related injuries. If you are injured at work, you typically cannot sue your employer as workers’ compensation is your exclusive remedy.

Understanding Workers’ Compensation

Workers’ compensation, often referred to as the “grand bargain,” provides no-fault benefits to injured employees in exchange for employers being immune from lawsuits. This means if your injury is job-related, workers’ compensation will cover your benefits, but you cannot sue your employer for additional damages.

Exceptions to the Rule

While the general rule is immunity from lawsuits if an employer has workers’ compensation insurance, there are rare exceptions. Some states allow employees to sue their employers under very limited and specific circumstances, such as intentional harm or egregious negligence.

Key Takeaway

In most cases, you are not able to sue your employer for a workplace injury if they have workers’ compensation coverage. However, understanding the nuances of your state’s regulations and the specifics of your situation can be crucial.

What should I do if I’m injured at work?

Getting injured at work can be a distressing experience, and it's crucial to handle the situation properly to ensure your health and protect your rights. Immediately after a workplace injury, there are two key steps you should consider.

Seek Medical Treatment

Firstly, seeking appropriate medical treatment should be your top priority. Depending on your state, you might be required to see a healthcare provider selected by your employer. However, in emergencies where the designated provider is not accessible, seek care from any appropriate available provider. Some states allow you to choose your own physician. Your employer often informs you of your options during employee orientation or through the personnel policy manual.

Notify Your Employer

Secondly, notify your supervisor or the responsible individual for injury reports as soon as possible. Most states have a notice period ranging from 30 to 90 days after the injury date. If notice is not given in time, your claim might be denied. It’s advisable to submit your notice in writing and keep a copy for your records.

Reporting to the Workers’ Compensation Board

After notifying your employer, they might need to report your injury to the workers’ compensation board. The reporting requirements vary by state; in some, a report is necessary only if you miss a certain number of workdays. You should receive a copy of the official filing, often called a "first report," to check for accuracy. If you haven't received it, request it, and ensure all details match the report you initially provided. If you notice any discrepancies, request amendments to accurately reflect the claim details.

For more detailed information about workers’ compensation requirements and your rights, consider reviewing your state-specific guidelines or consulting a legal professional familiar with workplace injuries.

Why is my treatment being denied through my employer or carrier?

EUnderstanding why your treatment is denied by your employer or carrier can help you navigate the workers' compensation system more effectively. Employers have the right to contest the payment of both indemnity and medical benefits for various reasons.

Common Reasons for Treatment Denial

  1. Incomplete Paperwork: Insufficient documentation can lead to denial.
  2. Inappropriate Treatment: Treatments not deemed appropriate for the injury may be contested.
  3. Unapproved Doctor: If the doctor is not approved by your employer or insurer, this could result in denial. 

Utilization Review (UR) and Its Impact

In some states, a process known as Utilization Review (UR) allows employers or insurance carriers to assess and possibly remove certain medications or treatments from your plan. If your treatment doesn't align with a UR recommendation, it might be contested.

What to Do If Your Treatment Is Contested

When treatment is challenged, your employer typically must notify your state's workers' compensation agency and explain the reason for denial. As an injured worker, you can contest this denial through formal state procedures and argue why the treatment should be approved.

Post-Settlement Treatment and Medicare Set Asides

If your claim is settled and includes funds earmarked for future medical treatment, these decisions are generally between you and your physician. However, if a Medicare Set Aside (MSA) is involved, you must ensure that expenses paid by the MSA are related to your initial injury and are covered by Medicare, as per the Centers for Medicare and Medicaid Services’ (CMS) guidelines.

For detailed information on contesting treatment denial, you may want to consult your state's workers’ compensation agency or a legal professional.

Can I seek medical treatment with a doctor of my own choosing?

In the context of workers' compensation, whether you can choose your own doctor largely depends on the specific regulations of your state. Most state Workers’ Compensation Acts address this question, allowing for varying rules regarding medical treatment choice.

State Specific Rules for Choosing a Doctor

In several states, your employer has the authority to select the doctor who will treat you following a work-related injury. However, exceptions exist although they are often limited. Often, an employer may have the right to choose the treating physician for a specified period, such as the first ten days of active medical care. Conversely, some states allow injured workers to select their treatment provider from the outset.

Can I Change My Doctor?

A common follow-up question is whether you can switch doctors if dissatisfied with the current treatment. In states where the employer initially chooses your physician, a change usually requires approval from either your employer or a governing agency. If you initially selected the doctor, many states permit a single change without needing agency approval. It's important to note that seeking multiple changes, often termed “doctor shopping,” is generally disfavored and could result in being liable for personal payment for medical services. Always verify the payment obligations for medical treatment before incurring bills.

Final Thoughts on Choosing and Changing Doctors

Understanding your rights and responsibilities under your state’s Workers' Compensation laws is crucial when it comes to choosing or changing your doctor. For more detailed information specific to your state, it's advisable to consult legal guidance or refer to your state's Workers' Compensation resources.

Do I have to settle my workers’ compensation case?

A Workers' Compensation Settlement is a voluntary agreement between an employer (or their insurance carrier) and an injured worker. This agreement provides a predetermined amount of money, either as a lump sum or as an annuity, to cover the injured worker's lost wages, future earnings, and medical expenses for the remainder of their life.

What is a Workers' Compensation Settlement?

A Workers' Compensation Settlement involves a financial agreement to resolve a compensation claim. It is crucial to understand that no party can compel another to settle; it is entirely voluntary. Settling means agreeing to give up all rights under your state's Workers' Compensation Act in exchange for a financial settlement.

Settlement Options

In most jurisdictions, a full and final settlement of all rights under the state Workers’ Compensation Act is an option. However, some states do not permit full and final settlements. The choice to settle is significant and should be approached with careful consideration.

Seeking Professional Guidance

If you are contemplating a settlement, it is highly advisable to seek expert advice. Professionals with experience in settling Workers' Compensation cases can provide valuable guidance to ensure that your rights and future needs are adequately addressed.

Important Considerations

While a settlement can provide financial stability, it requires relinquishing all rights under your state's Workers' Compensation Act. This decision should be informed and well-advised.

How do I settle a workers’ compensation case?

Settling a workers' compensation case involves an agreement between the injured worker and the employer or insurance carrier. This settlement can be in the form of a lump sum or an annuity that covers lost wages, future earnings, and medical expenses for the remainder of the worker’s life.

Understanding Workers' Compensation Settlement

A workers' compensation settlement is a significant decision. Consider the trade-offs carefully, including any intangible benefits you might be receiving, such as no longer needing prior approval for medical treatments. Post-settlement, decisions about medical treatments can be made without prior approval.

Managing Your Settlement Funds

In cases involving a Medicare Set Aside, there are specific CMS guidelines for managing your medical funds. Understanding these rules is important to properly handle your settlement. Upon settlement, you will manage your own indemnity payments, as regular checks from an employer or insurance will stop.

Full and Final Settlement

Most states allow for a full and final settlement, meaning the employer pays a lump sum or structured settlement. After settlement, ongoing medical costs should be paid from your medical fund, as the employer or carrier won't cover these expenses.

Calculating Settlement Value

Settlement value calculations include past and future indemnity benefits and future medical expenses. This calculation might involve factors such as life expectancy, state-specific COLAs, and anticipated medical needs. Sometimes, expert medical personnel are involved to estimate future medical costs.

The Settlement Approval Process

Once the parties agree on a settlement, it must be reviewed by the state Workers’ Compensation agency. Approval involves filing documents and possibly attending a hearing before an Administrative Law Judge or Commissioner who ensures the settlement serves the best interest of the injured worker.

Following Guidelines and Securing Approval

For those settlements involving a Medicare Set Aside, it is crucial to follow CMS guidelines. Detailed information on these guidelines can be found in the [CMS reference guide](https://www.cms.gov). Once a settlement agreement is prepared, obtain necessary approvals to ensure it aligns with legal requirements and serves the injured worker’s best interest.

How is a workers’ compensation settlement calculated?

Calculating a workers’ compensation settlement involves two key components: the indemnity benefits and the value of future medical expenses. These elements are considered on a case-by-case basis, ensuring each settlement reflects the unique circumstances of the claim.

Components of Workers’ Compensation Settlement
 
Indemnity Benefits

The indemnity benefits typically include future payments, though in some contested cases, back owed benefits may also be considered. These benefits could last for the injured worker’s lifetime or be limited by state-specific duration rules. It's common to reduce future benefits to present value, based on the principle that future payments, if made today, should be discounted. Some states may bypass this calculation if periodic cost of living adjustments are applicable.

Future Medical Expenses

Assessing future medical expenses usually requires the expertise of a medical professional specializing in workers’ compensation cases. Occasionally, experienced legal counsel may also handle these calculations. Employers or their insurance carriers often initiate settlement discussions, either by requesting a demand or proposing a settlement offer. Such offers typically serve as a preliminary gauge of the claim’s potential value.

Factors Influencing Settlement Value

The valuation process is inherently imprecise due to various intangible factors that either increase or decrease the claim's value. Considering settlement? Consulting with an experienced professional is advisable, as their negotiation skills can be pivotal in reaching a favorable outcome.

Additional Considerations

Arriving at a settlement value is not an exact science. The variability in case specifics means that retaining someone seasoned in workers’ compensation settlements can significantly benefit an injured worker. External resources, such as legal guides or professional consultations, may be valuable for deeper insights into this complex process.

When would I need an Medicare Set Aside?

Understanding when you need a Medicare Set-Aside (MSA) is crucial, particularly if an individual is eligible for Medicare due to traditional Social Security or Social Security Disability. An MSA ensures that funds from a settlement are allocated to cover future medical expenses that otherwise would have been paid by Medicare.

Purpose of a Medicare Set-Aside

Medicare acts as a secondary payer, which means other available insurance sources must cover medical expenses first. In workers’ compensation or liability situations, if the case is contested, Medicare might initially cover medical expenses until liability is determined. These payments are considered conditional. Once resolved, Medicare expects reimbursement for these payments if another payer is responsible.

Importance of an MSA

For Medicare-eligible injured workers or liability claimants considering a settlement, an MSA becomes critical. It ensures that funds from the settlement specifically cover future medical expenses that Medicare would typically handle. It's essential because, despite settlement, Medicare remains a secondary payer. The settlement doesn't change that status but shifts the responsibility for future medical costs to the settling party from the insurance company.

Key Points to Remember

Medicare's Role: As a secondary payer, Medicare insists all other insurance must pay first before it covers medical expenses.

Post-Settlement Responsibilities: After a settlement, the responsibility for future medical expenses shifts away from the insurer and onto the individual involved in the settlement.

What is my obligation to Medicare?

When involved in a workers’ compensation claim and covered by Medicare, your primary duty is to protect Medicare's interests as it acts as a secondary payer. This means ensuring that primary payers, like your employer's insurance carrier, fulfill their responsibilities without Medicare covering related medical expenses.

Your Role as a Primary Payer

After your workers' compensation case settles, especially if it includes future medical expenses, you take over the role of the primary payer. This involves properly paying your medical bills using the settlement funds until they are depleted. You also have the option to transfer this responsibility to a professional management company.

Guidelines for Medicare Set Aside (MSA) Funds

When settling with a Medicare Set Aside, you need to follow these CMS guidelines: 

  • Usage Restrictions: MSA funds can only be used for Medicare-covered treatments related to your injury.
  • Account Requirements: Funds must be kept in a separate, interest-bearing bank account.
  • Record Keeping: Maintain copies of all bills and receipts.
  • Annual Reporting: Report all expenses to CMS annually and whenever funds are exhausted.
  • Cost Compliance: Adhere to state fee schedules or "usual and customary" pricing for treatments and prescriptions.

Detailed Obligations and Resources

The obligations to Medicare continue post-settlement. For more detailed guidance and specifics on handling your Medicare Set Aside, including more complex language and scenarios, refer to the CMS Guidelines and Reference Resources. This ensures full compliance and proper fund management.

Key Resources for Managing Settlement Funds 

When you settle a claim, your future benefits are condensed into a single settlement sum paid either as a lump sum, structured annuity, or a combination of both. A structured settlement broker can be an invaluable resource, assisting you in managing these funds effectively, particularly for long-term security. 

Role of a Professional Administrator 

A reputable professional administrator is essential if your settlement involves a Medicare Set-Aside Account. They can help navigate the complexities of medical and pharmaceutical billing, bill paying, rate negotiating, and resource management. Understanding medical bills and managing them after settlement can be an unfamiliar challenge for many, but professional assistance ensures the process is seamless and compliant. 

The Centers for Medicare & Medicaid Services (CMS) recommends having a professional administrator due to the complexity involved in handling these funds responsibly. 

Seeking Legal Advice Post-Settlement 

If you had legal representation during your settlement, discussing your future plans with your lawyer can provide invaluable insights and recommendations. This conversation can help in planning and securing a productive future. 

Are there resources to help me manage the settlement funds?

Settling a claim is a significant life event. After settlement, many of the resources available to provide guidance and support disappear. If represented, your lawyer will likely close your file. You will no longer have an adjuster, medical case manager, or vocational counselor working with you. You will lose the support of your state Workers’ Compensation agency—it no longer has jurisdiction over your case. The good news is there are resources available to help. Two are of importance. When you settle a claim all your future benefits are reduced to a single number and that sum is paid to you. Your settlement can be paid in a lump sum, a structured annuity, or a combination of the two. A structured settlement broker can help you manage your settlement proceeds for the long term. Unless you are experienced in managing large sums of money, having someone with that skill work with you, affords the opportunity to make your settlement funds last longer and be secure in the process.

The second resource is a reputable professional administrator, like Ametros, that helps you manage the funds intended for future medical treatment. If there is a Medicare Set-Aside Account, a professional administrator can guide you through the complicated world of medical and pharmaceutical billing, bill paying, rate negotiating, and resource management. Many injured workers have never seen a medical bill associated with their claim. They have never reviewed a bill for accuracy and have never paid a medical bill associated with their case. Once a case settles, all those tasks and more become their responsibility. Having a professional administrator manage your settlement funds is highly recommended by The Centers for Medicare & Medicaid (CMS) because they understand how complex this process can be. There may be others who can provide guidance, direction, and support. If represented by counsel during the settlement process, a frank discussion about your post settlement hopes, dreams, and concerns should result in fruitful recommendations on how to plan for a productive and meaningful future.

What should I do if I reported a work injury, my employer filed a First Report, but then denied workers’ compensation benefits?

Having a work injury claim denied after filing can be frustrating, but understanding your rights and the available recourse can empower you to take the right steps.

Contesting a Denied Workers’ Compensation Claim

While workers' compensation aims to provide swift administrative processing, employers and insurers may contest claims deemed non-compensable. If your claim is denied, you should be informed within certain timeframes and have the right to contest through established procedures in your state.

Filing a Benefits Claim Form

Each state has protocols for administratively processing your case. Filing a benefits claim form, often called Petitions for Award of Compensation, is typically required. Navigating this process can be complex, and obtaining a worker’s compensation attorney experienced in your state’s system could be beneficial.

Seeking State Workers' Compensation Board Assistance

Your state’s Workers' Compensation Board or Commission can offer guidance, help in filling out the necessary paperwork, and manage claims. Many states have staff designated for assisting employees through the process.

For more information or additional assistance, it is recommended to reach out to your state’s specific workers’ compensation resources.

Can't find the answer you were looking for?

Our team will do their best to help find what you’re looking for.
After submitting the form our team will reach out to you within one business day.