Rafael Gonzalez is Vice President of Strategic Solutions at PMSI/Progressive Medical, soon to be known as Helios.
Over the past several years, the Centers for Medicare and Medicaid Services (CMS) have imposed stricter Medicare Set-Aside (MSA) guidelines as part of its ongoing effort to preserve the Medicare trust fund. Combine this change with the rising cost of medical treatment and the outcome is often a noteworthy increase in reserves and settlement values. Because of this, cases are remaining open longer or not settling at all. In fact, research by the Workers' Compensation Research Institute (WCRI) shows that injured workers disabled for longer than six months have less than a 50 percent chance of ever returning to their job. After a year, the chances that they will return to work drop to a mere 10 percent.
Proactive management throughout the life of the claim can be influential in driving down high medical costs and obtaining optimal outcomes for the injured worker. How you approach claim management, however, may depend upon the timeline for settlement. For example, if a claim is 12 – 18 months from settling, there is more time to implement clinical recommendations that affect future pharmacy cost and utilization whereas a claim on the verge of settlement may offer fewer alternatives.
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