Medical Expense HopScotch

Injury claimants are most likely to accept a settlement offer that 1) takes care of liens without wiping out the entire settlement and 2) provides a safety net for their future medical care. In mediation, I try to prompt negotiators to present proposals which show how a demand or offer addresses these issues. To do this, negotiators must review past medical expense records, understanding that claimants may hopscotch among payors or have concurrent payors as their status changes.

Private insurance Most Americans under 65 get health insurance through their or a family member’s employer. Some people may have purchased health insurance through an Affordable Care Act exchange such as; depending on their income, they may receive subsidies to reduce the premium. Claimants who are no longer able to work, and now have a pre-existing condition, may have transitioned from an employer’s plan to an Affordable Care Act plan. Some claimants may be self-procuring health insurance, including Medicare enrollees buying supplemental plans known as Medigap insurance and Part D prescription drug plans.


Workers Compensation will have paid past medical expenses for an accepted industrial injury.


Medi-Cal pays medical expenses for low-income individuals who qualify


Medicare provides medical care for disabled people who have qualified for Social Security Disability Insurance after 30 months, as well as for Medicare enrollees  who have reached  normal retirement age.


Out of pocket – Those with the financial ability to do so may self-pay when they lack insurance or want a procedure the insurer has denied or stalled.


“On a Lien” – When an attorney refers the client to a medical provider who provides services without charge, the provider has a lien on the ultimate case proceeds.


Every one of these possibilities (other than expenses paid out of pocket by the rare individual who can afford it) can give rise to a lien which must be resolved before settlement proceeds can be distributed. Negotiators should determine the extent of such liens before coming to mediation and be prepared with a plan to fund the injured person’s future medical needs.