by Andrea Mills, Chief Client Officer, Ametros

Strategies to streamline efficiency and effectiveness in medical settlement processes

The settlement of a workers’ compensation or liability claim should ideally benefit both the injured individual and the payer. However, numerous obstacles and confusion surrounding the intricacies of both systems and the management of medical funds post-settlement can hinder or even prevent the closure of medical cases.

This three-part article series addresses common questions about medical settlements, including Medicare Set-Asides and how Professional Administration can be a game changer.

In this final installment, we will delve into optimizing the use of Professional Administration, focusing on when and how to engage a professional administrator, leveraging best practices to optimize settlement agreements, and extending settlement funds.

When And How To Engage A Professional Administrator

As we have addressed in this three-part series, there are many obstacles to navigating and creating a successful win-win settlement. The best time to involve a professional administrator in a claim is early in the claim cycle to maximize the value they can bring to the case. By being involved early, the administrator can explore multiple options and tailor their approach to address the specific needs and concerns of the injured worker, ultimately leading to a more efficient and effective settlement process. This proactive approach not only aids in overcoming obstacles but also ensures that all potential solutions are considered, resulting in optimal outcomes for the injured worker and the payer.

Specific triggers can indicate that an injured worker may be ready to settle their claim. The first and most significant trigger to begin considering settlement is when the injured worker is medically stable and consistent in their pharmacy. Additional triggers for considering settlement include the injured worker’s frustration with constant denials for medical treatment within the workers’ comp system, concerns about financial stability and supporting their family, fatigue from undergoing independent medical exams and dealing with utilization reviews, and irritation with the restrictions imposed by the workers’ comp system. These individuals often desire the freedom to see their own doctors and are apprehensive about managing Medicare and MSA reporting requirements.

To engage a professional administrator effectively, the process can be as simple as calling up and saying “hey, we’ve got this case.” The professional administrator will discuss the case’s specifics, determine if it’s a candidate for a settlement, and then talk through the next steps and where to start.

Professional administrators can also help identify which cases could be good candidates for settlement through a file review process. Claim information to provide for a file review includes:

• The injured worker’s attorney, if he is represented.
• The employer’s or TPA’s contact information.
• A brief synopsis of previous settlement discussions.
• Medical cost projection if available.
• MSA if available.

Let’s take a look at some of the best practices for optimizing settlement agreement

The promise of ongoing support after the claim has closed can be the difference between a claim remaining open and a resolution. It provides a level of comfort to injured workers who feel overwhelmed that they will continue to have an expert to help them navigate the medical system, deal with attorneys, report to Medicare, and address concerns about money going forward.

Practicing Empathy

The skills of empathy and understanding cannot be overstated as a requirement of a successful settlement. Find out what’s going on in the heart and mind of the injured worker, his challenges, and his hopes and dreams to develop a settlement agreement that meets his unique criteria.

Professional administrators should invest time in understanding the injured worker and their family, attentively listening to their wants, fears, desires, and worries. Do they have family needs? Are they trying to start a business? Is there a spouse with specific goals or desires? Are they trying to put their kids through college? What elements have significant importance in their life?

Account for Non-Medicare Medical Needs

Once the injured worker understands the professional administrator is there to help, he is more likely to open up and have conversations that will lead to an optimal settlement agreement that addresses their emotional and medical needs.

The professional administrator’s role is to care for the injured worker, ensuring he has information and access to the best medical care and helping extend his settlement money to last his lifetime.

One area that is often missed in settlement agreements is accounting for non-Medicare medical needs.

By considering medical needs not covered by Medicare, the settlement can reassure the family that funds have been earmarked to manage such expenses, offering them relief and peace of mind. Such information can be integrated into the settlement agreement to ensure all needs are covered.

This may include money for such things as:

1. Medications not included in the MSA (if they are not covered by a spouse’s group health plan)
2. The expenses associated with a family member attending to the care of the injured worker or for the family to pay for an attendant
3. Relief for family members upon death
4. Home or car modifications that are not covered by Medicare
5. Health plans to assist with additional coverage including, Medicare Advantage Plans and Medi-gap plans

Account for Long-Term Healthcare Needs

While the services of professional administration are a tremendous benefit and offer peace of mind for the majority of injured workers who settle their claims, some need additional help and support.

An optimal settlement agreement will account for the additional services required for these individuals with long-term healthcare needs, including:

• Durable Medical Equipment (DME) Support: An administrator can support an injured individual and their family in finding and purchasing DME, including modified vehicles, adaptive equipment for current vehicles, and home modifications.
• Long-term healthcare support for complex/catastrophic cases: Complex/catastrophic cases require one-on-one support and a holistic focus on the injured worker that provides guidance on treatment plans, medications, surgeries, and other concerns. A professional administrator can empower injured workers to make informed healthcare decisions and take control of their lives. Additional benefits include ensuring timely medication supplies, discussing post-surgical complications, providing insights into the long-term effects of treatments, coordinating unexpected treatments, addressing durable medical equipment needs, and identifying potential savings.
• Extending settlement funds: administrators typically work with various providers and pharmacies to offer significant discounts to help preserve the individual’s settlement funds.

Transitioning Care To Professional Administration

Transitioning care to professional administration begins with a straightforward onboarding process, where the administrator reviews the injured worker’s case details and discusses the next steps. This initial phase ensures that all relevant information is gathered to tailor the support to the individual’s needs.

Post-settlement, the professional administrator becomes the manager of the injured worker’s care and a trusted resource for the injured worker to reach out for help. This continuous support offers the injured worker and their family peace of mind, ensuring that their healthcare and financial concerns are effectively managed.

Conclusion

In conclusion, optimizing settlement agreements through Professional Administration provides a comprehensive, empathetic, and strategic approach to resolving workers’ compensation and liability claims. By engaging professional administrators early in the claim cycle, parties can navigate the system’s complexities more effectively, ensuring that settlements are fair and just and tailored to the injured worker’s specific needs. This holistic approach, which includes addressing non-Medicare medical needs, leveraging medical discounts, and ensuring ongoing support, ultimately leads to better outcomes for both the injured individual and the payer. By incorporating these best practices, settlements can truly become a win-win solution, offering peace of mind and financial security for all parties involved.

Andrea Mills, Chief Client Officier, Ametros. Andrea focuses on growing business and partnering with clients to find solutions that best fit their needs or solve problems. She has been in the workers’ compensation space for over ten years, starting her career as a marketer for a case management company, and transitioning to a sales role for a large provider of ancillary services in the WC space.