As much as some injured workers’ complain about workers’ compensation, the system has some perks like a nurse case manager and adjuster to help coordinate appointments, deal with the administrative burden, and check in to ensure everything is going smoothly on the claim. Giving up this support can be a paralyzing fear and prevent a claim settlement. This challenge is particularly true in complex catastrophic cases.The good news is professional administrators are becoming increasingly popular — even Medicare “highly recommends” using them. Some of these organizations are going the extra mile to provide true one-on-one help for injured workers with complicated needs.
Professional administrators handle many of the administrative tasks on behalf of the injured worker once they've settled their Workers' Compensation claim.
Managing the settlement money, paying medical bills, and complying with government regulations such as Medicare reporting requirements can be a nightmare. The professional administrator acts as an advocate for the injured worker to ensure they successfully navigate the health care system post-settlement.
Additional tasks include:
- Finding and setting appointments with appropriate physicians and specialists
- Taking care of all durable medical equipment needs
- Ensuring that, at the very least, any payments for medical care don’t exceed the state’s medical fee schedule
- Deciding whether recommended medical procedures should be undertaken
The role of the professional is to guide the injured worker through this process, by
- Coordinating medical care
- Processing medical payments
- Applying discounts to medical office visits, medications, and procedures
- Performing annual prescription reviews to assess medications that are prescribed
- Complying with government requirements
- Answering any questions of the injured worker
Post Settlement Help for Catastrophic Cases
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. For them, a new service is appropriate.
Some professional administrators have developed teams of nurse care partners that specifically focus on injured workers with particularly complex medical situations; those who are brain injured, wheelchair bound, suffering with limb loss and depression and have difficulty with activities of daily living. Many in this situation are hesitant to settle their workers’ compensation claim because they will lose their support system, despite the shortcomings of the workers’ comp system.
This innovative solution provides holistic focus on the injured worker. Nurse care partners will engage in conversations with injured workers, providing guidance and support about their treatment plan, medications, upcoming surgeries and any other concerns they have. This discussion allows the injured worker to make informed decisions about their health care, empowering them to take control of their lives. Additional benefits they provide include:
- Ensure monthly supplies of medications are provided on time
- Discuss potential post-surgical complications and recovery
- Provide insights into the long-term effects of medications and treatments related to the injured worker’s condition
- Assist injured worker in understanding their healthcare options, empowering them to make their own healthcare decisions
- Coordinate treatments for any unexpected complications that may arise
- Finding solutions to durable medical equipment needs
- Identify and discuss potential savings opportunities with the injured worker so they can make their own informed decisions
- Provide one-on-one support
Case Study: Henry* (case study provided by Ametros)
Henry* had lost both legs after a severe motor vehicle injury over two decades ago. In addition to his medical issues, he also suffers from depression, anxiety, and Post-Traumatic Stress Disorder.
Roadblock to Settlement
- The only thing stronger than Henry’s desire to settle his claim was his concern over losing the support of the nurse case manager with whom he had developed a close relationship throughout the years.
- He learned of the post-settlement assistance he could receive through a professional administrator, and was encouraged to settle, though not fully convinced.
- He knew he required an extra level of support.
Catalyst to Settlement
- What ultimately changed Henry’s mind was learning about Ametros’ Health Navigator service and how its post-settlement care could impact his life.
- As promised, Ametros sent a nurse, Melody, to meet Henry and conduct a wellness assessment in-person to understand all of his wants and needs. She established a direct line with Henry, built a rapport and let him know she would be available to help him navigate the complex healthcare system.
- Before Henry settled his claim, Melody gathered all the medical information needed to make sure the transition would be smooth.
- Henry settled his claim last December and Melody continued to act as Henry’s dedicated Care Partner.
- Since then, Melody has been working with Henry closely. Initially, Henry contacted Melody multiple times each day with questions and concerns she could help address. His contacts are less frequent now, but he has come to trust and rely on her to be his advocate.
*name changed for privacy
Knowing that someone will be available to help navigate the complicated healthcare system leads many injured workers with long-standing claims to agree to settle. Now there is an extra layer of advocacy to help the most seriously injured take charge of their lives.