By Krista Johnson, Senior Director of Special Programs and Andrea Mils, Executive VP, Sales, Ametros
When settling a workers’ compensation claim involving a catastrophic injury, insurers and other payers need to prioritize the future management of medical funds. These workers’ comp patients usually require expensive and complicated life-long care. Their medical funds need to be protected from premature exhaustion and Medicare needs to be protected from paying for injury-related care.
Complex injuries, such as traumatic brain injuries, amputations, spinal cord injuries, and severe burns can leave the patient wheelchair-bound or even bedridden, needing assistance to use the bathroom, bathe or eat. The unique physical and emotional needs of someone who has suffered a catastrophic injury typically require specialized care from teams of experts.
Recognizing the special needs of these workers’ comp patients, payers often partner with companies that specialize in managing catastrophic workers’ comp cases. And the same level of care needs to continue after the claim closes.
What to Know Before Settling
While the claim is active, injured workers receive guidance, medical treatment, and sometimes psychological services along with medication, durable medical equipment, physical and occupational therapy, home and vehicle modifications, and supplies. A case manager helps navigate the medical system, advises and answers questions about their care, and handles the administration. The workers’ comp program typically coordinates and pays for everything.
After maximum medical improvement is achieved, most seriously disabled workers still need treatment, medication, and a host of other services. Wheelchairs require maintenance and repairs. Prosthetics must be continually monitored for proper fit, and new parts, supplies and replacements will be needed. Complex rehab technology will eventually need repairs, updates or replacements to accommodate the injured person’s changing body.
Many injured workers erroneously assume these ongoing services will be handled in the same way after settlement. The reality is they or their caregiver need to find their own specialists, make appointments, and pay for all their injury related care from settlement funds.
That is a lot for a seriously injured worker or their family.
It gets even more complicated. Many catastrophically injured people qualify for Medicare and their settlements typically include Medicare Set-Asides. Future medical costs that are for services and products covered by Medicare are allocated in an MSA.
Yet Medicare does not cover many of the services injured workers previously received from workers’ comp and these cannot be paid through the MSA. For example, Medicare cannot reimburse some home-health services and equipment and the off-label use of certain prescription drugs. Monies for Non-Medicare-covered treatment, equipment, and other physical needs are placed in a separate account. (Determining these future medical expenses, preparing MSAs and allocating other future medical expenses are extremely complicated and best left to experts, such as an MSA company.)
Managing different medical funds and adhering to reporting requirements challenge most people and can prove impossible for a seriously disabled worker and family. Just knowing which account to use for which service can be overwhelming.
During settlement discussions, it’s important to set injured workers’ expectations about managing their care, its costs, and medical funds after settlement. They also need to understand reporting requirements for MSA expenditures and risks of non-compliance if they administer their own MSAs.
Payers who educate injured workers on their responsibilities and offer them fund management solutions take a big step toward a smooth settlement. Knowing the money is properly handled and reported goes a long way to improving the injured person’s quality of life. Following are a couple of medical fund management vehicles:
Trusts
Special Needs Trusts are commonly used to manage complex settlements when the injured person has been deemed disabled the Social Security Administration. Let’s say an injured worker is receiving Social Security Disability Income and Medicaid while waiting for Medicare benefits to start. Medicaid covers in-home health services that will be needed long term and Medicare does not cover these.
An SNT created for the entire settlement could include funds to be spent on allowable items in the trust, the MSA for Medicare-covered injury-related treatment, and a separate account for care Medicare does not reimburse. Working with an experienced trustee and professional administrator will ensure compliance for needs-based benefits and Medicare.
Professional Administration
Professional administrators manage medical fund accounts for different purposes, including MSAs and funds for care Medicare does not cover. They also provide MSA reporting and other government reporting services, ensuring the injured worker remains in compliance.
Knowing when, how and where to obtain products and services is tricky. Some professional administrators have durable medical equipment networks and offer pharmacy discounts. And they make sure the right services are paid from the right accounts.
Additionally, they simplify medical payment processes. Some provide a card similar to an insurance card so payment transactions occur electronically. A few companies go beyond this to ensure the coding is accurate and medical bills are paid at applicable state fee schedules. The injured person and their family do not have to deal with the paperwork and can access the accounts at any time.
A best-in-class professional administrator also understands the nuances of complex cases and will have a team to manage them. Ideally there’s a single point of contact and the team serves as a one-stop solution for all treatment, home health care, medical equipment, prosthetic care, and supplies.
Summary
People who have suffered catastrophic injuries have enough to deal with without worrying about compliance, reporting, finding specialists, or getting equipment repaired. Payers can pave the way to faster, smoother settlements and a higher quality of life for these patients by providing care advocation services and protecting funds for future medical expenses.
About Krista Johnson
Krista has an extensive background in the special needs trust and managed care industry. In addition to being well versed in Medicare, Medicaid and CMS regulations, she is a regular participant in various conferences and panel discussions within the industry.
Krista obtained her B.S. from Indiana State University. She also serves as an alumnae representative to the Indianapolis 500 Festival Princess Program, and actively volunteers with the Cystic Fibrosis Foundation. She currently resides in Indianapolis with her husband Clayton, and dog Lily. Krista is active in coaching and the judging of competitive cheer competitions, and also enjoys boating and participating in half-marathons.
About Andrea Mills
As the Executive Vice President of Sales, Andrea Mills leads the education and sales strategies for Ametros. Bringing Ametros’ solutions to new markets, managing relationships with carriers, TPAs, brokers, and employers. She and her team create innovative settlement strategies and programs for all parties involved in settlement focusing on education and ensuring injured parties have resources available to them after settlement. She has been in the workers’ compensation space for 17 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.
Andrea has experience monitoring product success through product delivery and sales enablement, and has a BA in Music from Catawba College. She currently resides in Florida with her family, enjoys heading to the beach and loves a good barre class!
About Ametros
Founded in 2010 and headquartered near Boston in Wilmington, Massachusetts, Ametros is the industry leader in post-settlement medical administration and a trusted partner for thousands of members receiving funds from workers’ compensation and liability settlements. The company makes healthcare easy for injured individuals and other people who pay for their medical care out of pocket. Ametros’ mission is to protect and empower the future of medical care by helping its members save money on medical expenses and save time and reduce frustration dealing with the complex healthcare system. Ametros may be reached at 877.275.7415 or via www.ametros.com.