Workers’ Compensation FAQs

Q: What is workers’ compensation?

A: Workers’ compensation is a no fault system that was put into place to provide employees compensation if they are injured at work. In general, all employers are required to have workers’ compensation insurance for their employees, excluding independent contractors among a few others. Workers’ compensation covers short-term, long-term, and permanent injuries. This also means the injured workers will receive insurance benefits and treatment regardless of who was at fault. Individual states have different requirements, which can be found on your state’s workers’ comp website.


Q: Can I sue my employer for a work injury?

A: No, in general, you cannot sue your employer for a work injury. The workers’ compensation system was put in place for this reason, to limit litigation and setup a process for the provision of benefits.


Q: What should I do if I’m injured at work?

A: Seek immediate help. If you are injured at work you should notify your supervisor about the injury as soon as possible, in writing. If an injury develops over time that was work-related, you may have between one and four years to file depending on the state the injury occurred in and its regulations. Time frames can be found in the Statute of Limitations. Your employer or insurer will likely provide you with a claims form, which you should fill out the Employee section completely, and deliver by hand or mail. Always make sure to request a signed copy of the form directly from your employer if possible, after he/she has submitted the form to the insurance company.


Q: When should I hire a workers’ compensation lawyer?

A: If you have questions about your injury and the workers’ compensation settlement process, you may want to speak with a workers’ compensation attorney who can look at your claim and help answer any questions you might have. Having a lawyer can also increase the likelihood of a fair settlement allocation. Cases when you should consider hiring a lawyer: - If your employer denies your claim - The settlement amount does not cover lost wages or medical bills - If you receive Social Security Disability (SSD) benefits.

You can find workers’ compensation attorneys through resources such as the Workers’ Injury Law & Advocacy Group. Workers compensations attorneys specialize in advocating for you to receive the full benefits available to you and will also help you assess whether settling your claim is worthwhile.


Q: Why is my treatment being denied through my employer or carrier?

A: Sometimes employers, insurance carriers, or third party administrators that manage your claim will dispute if your claim is work-related and/or deny your benefits. It may even be as simple as missing information on forms, which can be straightened out by calling the insurance company.

If your injury is accepted by the adjuster and the future medical portion of your settlement is open, when you are treating through the employer’s or carrier’s insurance, the adjuster may have the right to conduct utilization reviews or request independent medical examinations to determine if your treatment is necessary.

If you choose to settle your case, you will likely have more freedom to pursue the treatment you would like, without utilization review.


Q: Can I see the doctor I would like to see?

A: Depending on the state, your employer or insurance carrier may be able to direct your care and require you use a certain doctor. If you choose to settle your case, you will have more freedom to get the treatment you would like, without utilization review, and you will be able to see the doctors you prefer.


Q: Do I have to settle my workers’ compensation claim?

A: No, it is not required that you settle your workers’ compensation claim, but if you decide to settle your claim, there are services that help you navigate the process and ensure a fair settlement.


Q: How do I settle a workers’ compensation case?

A: Many times, injured workers choose to settle their workers’ compensation case, accepting a certain amount of money for their future medical care and any indemnity settlement. Your settlement could be split into two pieces, an indemnity portion and a future medical care portion. The indemnity portion is for your lost wages and future earnings, and does not carry any restrictions or reporting requirements. The future medical portion of your settlement is allocated for your future medical treatments for the rest of your life. This portion can contain certain reporting requirements with Medicare, and, if it is a Medicare Set Aside (MSA) then it is only to be used on treatments related to your injury and that would be Medicare-covered. A professional administrator, like Ametros, can help you manage an MSA.


Q: How is my workers’ compensation settlement calculated?

A: The two portions of your settlement, the future medical and indemnity, are calculated differently. The future medical treatment is typically calculated based on your life expectancy and the treatments you are expected to need for the rest of your life. The total amount could vary greatly depending on the severity of your injury, your current age, your health standing, and other complications that may arise from your injury. The indemnity portion of your settlement is based on an estimate of your future wages and your state’s rules and regulations. You can find out your state’s policies on workers’ compensation here.


Q: When would I need an MSA?

A: Any workers compensation settlement that includes funds for future medical care should take Medicare's interests into consideration. The most common way to do so, is to establish an MSA.

For more information on MSAs, please refer to our MSA FAQ page.


Q: What is my obligation to Medicare?

A: If your future medical funds from your workers’ compensation settlement are put into a Medicare Set Aside (MSA), you will have yearly reporting requirements that you must complete to Medicare. The top 4 MSA administration guidelines required by Medicare are:

• Funds will be deposited in a separate, interest-bearing account.

• All treatments and prescriptions need to be verified that they are related to the injury and covered by Medicare.

• Track all expenses, treatments, dates of service and related ICD- 9/10 codes annually; Reporting must be sent to the Centers for Medicare and Medicaid Services.

• Pay bill according to the specific state workers’ compensation fee schedule or “usual and customary” pricing.

If you do not comply with these obligations, you could be at risk for losing Medicare benefits. See the MSA FAQ's for more detail.


Q: Are there resources to help me manage the settlement funds?

A: At Ametros, we help injured workers manage any future medical funds after settlement. Our services, CareGuard and Amethyst, provide different levels of support to help you manage your medical care, access savings on treatments and prescriptions, and fulfill any required reporting to Medicare. It is never too early or too late to involve us in your settlement. We can walk you through the settlement process, and understand what will be required of you once you settle. We are offering injured parties the opportunity to set up a free settlement consultation to speak with our settlement advisors to better understand their settlement.

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