It’s not often you hear of the government endorsing a particular service in the private sector. That’s what made it so unusual when the Centers for Medicare and Medicaid Services in 2017 “highly recommended that settlement recipients consider the use of a professional administrator for their funds.”
The 2017 statement spoke volumes about the need for injured workers and others to get help managing their money and lives post-settlement. The concept of professional administration is, unfortunately, highly misunderstood by many workers’ compensation professionals. But once stakeholders are exposed to the ins and outs of this unique benefit, they realize how it can easily be a win-win for all parties to a claim – and why CMS encourages the idea.
What is Professional Administration?
The vast majority of workers’ compensation stakeholders are keenly aware and focused on injury prevention and claim management. What few stakeholders address, however, is that life after a claim is settled. Employers, payers, and injured workers alike usually want claims settled as soon as possible. It gets these cases off the books and allows the injured party to move on with his life.
The problem is the logistics of actually getting to claim closure. The biggest question for everyone involved is often, how much money will it take? The employer/payer wants an amount that will cover the injured worker’s needs, but that is also fair and accurate. The injured worker, understandably, may be extremely fearful that he will run out of money too soon.
In many cases, the claim has been open for months, if not years. While the workers’ compensation system may be seen as adversarial to the injured worker, it at least provides a sense of security that his medical needs are being covered – even if he doesn’t necessarily like the providers and does not always get approval for treatments he believes he needs. Settling the claim means the injured party is on his own to manage whatever funds he has agreed to. Additionally, where there has been a claims adjuster and/or nurse case manager helping him locate and schedule medical appointments, they are now gone. Many injured workers become anxious when they realize they will have to manage their case on their own once they settle.
Professional administrators work on behalf of the injured worker post-settlement in multiple ways.
- Clinical help. The professional administrator essentially takes over the role of adjuster/nurse case manager and provides the expertise, guidance, and logistical help so the injured party gets the medical care he needs. However, rather than having a specific group of physicians available and having to seek approval for treatments, the injured party is free to see any physician of her choosing and decide for herself whether to undergo certain medical treatments.
- Money management. All too frequently people settle their claims, take the money in a lump sum, and exhaust the funds within a few years. That is why experts strongly recommend structured settlements for injured parties who settle their claims. Depending on the injured party’s desires, the professional administrator can establish a bank account and act as custodian – receiving bills and paying them on behalf of the injured party.
- Savings. Well-established professional administrators can make a significant difference in an injured party’s life through medical discounts; for physicians, medications, treatments, and other medical-related items. The best ones have partnerships with many providers and can provide deep financial savings, helping to ensure the injured party’s money lasts longer.
- Medicare reporting. One of the issues that is often problematic for injured workers is addressing all the rules and regulations associated with Medicare Set-Asides. Injured workers who have an MSA as part of their settlements must strictly adhere to CMS’ requirements or risk losing Medicare benefits in the future. Professional administrators handle all annual reporting for MSAs and ensure that the funds are not used for the wrong purposes.
The Right Professional Administrator
There are many professional administrators and finding one that is the ‘best’ for a particular injured worker is not a decision that should be made lightly. Along with the injured party and his advocates, stakeholders working on a claim should also research various companies to help make the best choice. Stakeholders want to know the injured party is taken care of and won’t call them six months after settlement with complaints and threats to sue.
There are certain questions that can differentiate the best professional administrators and how well they will meet the injured party’s needs:
- Costs/savings. There is no free lunch, and just like any organization, professional administrators need to generate income. For those in the market, the price should balance against the savings to the injured party. One company may charge $1,000 while another charges $2,000. However, asking for the average savings in medical/pharmaceutical costs and savings on the MSA funds tells the real story of the ‘costs’ to the injured party over the long term. If a company does not track this information or won’t provide it upon request, that should serve as a red flag.
- The vast amount of medical and other personal information provided to a professional administrator must be protected. Find out what, if any steps the company takes to protect members’ information, whether they undergo routine technology and financial audits, and if they are HIPAA compliant.
- Customer service. The relationship between the injured party and the professional administrator is lifelong, so it’s important to know all questions and concerns will be taken seriously and addressed appropriately. Find out if and how the organization measures its customer service, such as through surveys of members. Talking with existing members is also a good way to determine the quality of a company’s customer service. The company should be willing to provide references and a look at a survey of members, if they exist.
- Technological convenience. Many people want to be able to get information online. Some professional administrators provide easy-to-access information, such as funds spent/remaining, names/addresses of providers, medications prescribed, recent visits, analyses of spending and savings, etc. On the other hand, some people are not comfortable with doing everything via phone/tablet/computer and should have the option of a phone number to call with their questions.
- Additional services. Professional administrators should have partnerships with many other experts that can help with post-settlement issues. The company should be able to provide lists of additional services, and experts offered.
A well-run professional administration company is an invaluable asset for an injured party who settles his claim. Those that have the most experience and expertise not only help these workers post-settlement, but their inclusion in the process often helps move claims to settlement more quickly.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is the founder & lead trainer of Amaxx Workers’ Comp Training Center.
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