Planning for care. For life.

What Happens After You Win the Legal Battle?

The Challenge

Winning a lawsuit may seem like it means your troubles are over – but the complexity of long term healthcare may mean winning brings new challenges.

For example, National Care Advisors was contacted by an attorney who had recently won a settlement for their client. An adult male who had sustained a permanent spinal cord injury was about to receive a $3 million dollar settlement after four years of suffering after the incident.  He had the benefit of private health insurance as well as Medicare and Medicaid benefits during this time period.

The concern? His health insurance company, Medicare, and Medicaid had provided the funding for medical care since the time of the incident. They then had a lien demand for reimbursement via the settlement proceeds due to the third party admitting liability for the incident.

Medicare also requires that the burden for future medical costs cannot be shifted to the Medicare system – so consideration was necessary regarding responsibility to pay for future medical costs from the settlement proceeds.

Additionally, the settlement funds could potentially interfere with the client’s future eligibility and access to essential Medicaid benefits that assist with the cost of home care services that enable the client to remain in his own home.

Our client and his attorneys had more questions than answers regarding how to make sure that his $3 million dollar settlement provided maximum benefit without adversely interfering with essential benefits.

Our Job

How does National Care Advisors help in a situation such as this? First, we complete a Lien Analysis – an essential analysis conducted to make sure that the lien repayment demanded by the insurance company, Medicare, and Medicaid accurately reflects the medical care that was 100% causally related to the lawsuit.  NCA nurses provide line item lien review to substantiate removal of line items that are not medically related to the lawsuit.  This can result in significant improvement in the amount of the lien owed. An attorney can then negotiate with the payer sources to make sure that any lien repayment is fair, given the scope of the client’s net settlement award.

Next, we look at a Third Party Benefits Analysis – The first essential step in determining the need to preserve eligibility for third party benefits is to project the likely value of those benefits to the client over their lifetime.

Once a reasonable value is projected, then the decision to preserve or not preserve access to those benefits in the future can be well supported.  NCA nurses provide the analysis data that assist clients and their legal advisors to determine the right course of action in managing the net settlement award.

The NCA Third Party Benefits Analysis provides essential information for the following decisions post settlement:

  • What are the third party benefits really worth to the client over his/her lifetime?
  • Is a Medicare Set Aside consideration important to the client to preserve future access to Medicare benefits?
  • Is a Special Needs Trust necessary to preserve future access to means tested benefits such as Medicaid, Medicaid Waiver Services or Supplement Security Income?
  • Does the client need assistance to administer and manage this large sum of money?
  • From a practical perspective, considering the value of unpaid family time and support, third party benefits value and the scope of the net settlement award – what sum of money is necessary on a monthly or annual basis to meet the client’s essential care and quality of life needs?

The analysis and consulting services of National Care Advisors provided essential information to the client, attorney, and financial advisor regarding the best disposition of funds post settlement.

The Success

For the client in this case, the attorney was able to use National Care Advisor’s research and analysis to negotiate the reimbursement of the original lien demand for a significant discount below what was originally requested.

In addition, the NCA third party benefits analysis revealed that in order to meet the client’s vision for quality of life, it was in his best interest to preserve access to both Medicare and Medicaid.  His settlement award would then be available to pay for a better home, better equipment, more support services, vacations and other quality of life costs beyond the basic medical care required.

With this very specific information, the client and his attorney were able to make timely decisions regarding the need for a Special Needs Trust and Medicare Set Aside account.  The client determined that given his personal circumstances, vision for quality of life and scope of the net award that the best approach was to preserve access to third party benefits over his lifetime.

At National Care Advisors, we focus on the long term quality of life goals of our clients, ensuring their financial resources are maximized and utilized to reach those goals.