Ametros Company FAQs

In CareGuard, Ametros provides professional administration services typically related to post-settlement medical funds. This means that people who have received a settlement typically from an insurance company or workers compensation claim to pay for the individual’s post-settlement medical expenses hire Ametros to administer the settlement on the individual’s behalf. Ametros calls these settlement recipients that elect to use our services, our “members.” Ametros places settlement funds in a custodial, interest-bearing bank account for the benefit of the individual member, and then pays medical claims out of the settlement funds on behalf of the individual member.  For more information see: ametros.com/careguard

In Amethyst, Ametros provides a platform typically used for self-administration of post-settlement medical funds. The settlement funds are placed by the injured individual into their own personal bank account. The injured individual provides Ametros with the debit card information for that personal account and permission for Ametros to charge the account for eligible medical claims. Ametros will receive medical claims on behalf of the member and review them for potential discounts and then charge the individual’s personal bank account. For more information see: ametros.com/amethyst

Both CareGuard and Amethyst typically provide members with access to discounted rates negotiated with medical providers that are part of the Ametros medical network. Both services provide online and mobile methods to access account information and to review medical claims processed and paid.

CareGuard is Ametros’ professional administration service your patient has selected to manage their medical fund account. Your patient sustained a work related or liability injury, which they settled in court. Upon settlement, they were granted funds to pay for their future medical care related to this injury. From this point on, CareGuard should be billed as the primary payer for all claims related to this injury. CareGuard is not an extension of Workers’ Compensation thus the same reporting rules, authorizations, and visit limits are not applicable.

The services received must be related to the members’ covered injury and, for a Medicare Set-Aside, be services that are covered by traditional Medicare.

CareGuard claims submissions are handled like traditional medical insurance.

Our Provider Services line, 1-877-905-7322 option 2, is available to check member eligibility and claim status from 9 a.m. to 6 p.m. EST Monday – Friday. You may also email questions to claims@careguard.com

CareGuard accepts claims typed on a CMS-1500 or UB-04. Please do not submit handwritten forms. Paper submissions should be computer generated or typed for scanning recognition.  Handwritten claims may be rejected causing a delay in payment.

We highly recommend submitting claims via our electronic payer ID, 20572. This will provide a shorter turnaround time and increased accuracy.

Claims may also be mailed to the following address:

MSA CareGuard
PO Box 25977
Tampa, FL 33622

Please note, we are unable to accept faxed or emailed claims.

Please include the CareGuard Member ID in Box 1A of the CMS-1500 or Box 60 of the UB-04.

To receive reimbursement a provider must have an NPI that matches/is registered with an existing tax identification number.  NPI requirements are federally mandated.  Further information on NPI is available at CMS.gov

Claims are typically processed within 10 business days and are paid using virtual credit cards (VCC).

The VCC will arrive in the mail and can be processed the same way you would process a patient’s credit card at the time of service. If your office does not accept credit cards, there is an option on the VCC to change your payment method to a check.

For problems processing the VCC, please call Data Dimensions at 631-648-6020 or email DDPaySupport@DataDimensions.com.

If a claim refund is required please follow the steps below:

Provider initiated refunds should include

• Member ID, Name, and DOB
• DOS
• Reason for refund
• Copy of the EOR

Response to CareGuard initiated refund request should include

• Copy of the letter you received
• Check made out to Ametros Financial Corporation FBO: (Member’s Name)

Mail to:

Ametros Financial Corporation FBO: (Member’s Name)
Dept 7710
PO Box 4110
Woburn, MA  01888-4110

Provider Authorization is NOT required for medical services but is recommended for services with a cost over $5,000. PT/OT/ST, radiology, and ESI do not require prior approval. There are no visit limits on therapies and no expiration dates for authorizations.

Requests for prior authorization may be faxed to 1-877-443-9344 or emailed to Claims@CareGuard.com. We recommend using the CareGuard Prior Authorization form. If you prefer using your own form, please include the following information:

• Member’s name, DOB, and CareGuard Member ID
• Rendering provider’s name
• Facility name
• Requested service with CPT codes
• Related diagnosis
• Estimated cost

DME items always require prior approval. Requests may be faxed to 877-443-9344 or emailed to DME@CareGuard.com. Please include the following information on any requests:

• Member’s name, DOB, and CareGuard Member ID
• Member’s address and phone number
• Provider’s name, address, phone/fax/email
• HCPCS, quantity, description, and price

When submitting a claim, please include the case number provided by CareGuard in Box 23, prior authorization number, of the CMS-1500 form.

Physical, Occupational, Speech therapy

Providers are required to include either GN, GO, GP modifiers per CMS Manual https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf

Chiropractors

Medicare guidelines limit services provided by chiropractors to 98940, 98941, 98942 billed with an AT modifier. Chiropractors are not authorized to perform x-rays or physical therapy.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/se1601.pdf

Drug testing

Please see the MLN Notice for appropriate drug testing codes.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18001.pdf

Psych providers

Although CareGuard does not limit service frequency we do follow Medicare guidelines regarding covered provider types. Please see here for a list of types.

https://www.medicare.gov/coverage/mental-health-care-outpatient

Home Health

For guidance on covered home health services.

https://www.medicare.gov/coverage/home-health-services

Platelet-rich Plasma Injections

PRP is only covered for patients meeting specific guidelines.

https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/Autologous-Platelet-rich-Plasma

Medication billed on a CMS-1500 must include both a J code and a valid NDC.

Unlisted/non-specific codes require supporting documentation. Please note, claims submitted with a non-specific diagnosis may be denied or rejected.

Massage therapy is only covered when rendered by a licensed physical therapist.

Post-Settlement Update link:

https://ametros.com/blog/post-settlement-update-cms-provides-instructions-to-providers-when-wcmsas-involved/

MLN link:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE17019.pdf

Ametros is a division of Webster Bank. For more information on Webster Bank visit www.websterbank.com.

Ametros is based in Massachusetts and subject to Massachusetts state law as well as applicable Federal laws. Guidelines for administering Medicare Set Aside accounts are outlined by the Centers for Medicare & Medicaid Services (CMS). There is no regulatory agency or specific rules or regulations governing professional administration of settlement funds or Medicare Set-Aside accounts.

Some Ametros members have a special kind of settlement called a Medicare Set-Aside Account, where the member agrees that the funds in the account are restricted and can only be used to pay for certain medical costs that are related to the injury that gave rise to the settlement and that would have been covered by Medicare. Ametros requires a signed member agreement from each member whose funds are administered on its CareGuard platform. This agreement provides clarity on Ametros’ responsibilities and how Ametros performs its duties, benefits the member and is compensated for its work, and how Medicare reporting is completed. Ametros’ business model has been vetted by our internal and external legal counsel to ensure it complies with all regulations. Ametros also receives oversight of its business practices and Medicare compliance obligations from its independent regulatory council comprised of industry experts. Learn more about our regulatory council here: https://ametros.com/regulatory-council/. In addition, Ametros undergoes regular security and IT audits to ensure its systems are safe and in compliance with industry standards. You can learn more about Ametros’ security here: https://ametros.com/security/.

Ametros members are not restricted to Ametros’ medical network partners and can choose to go to any pharmacy or provider they would like in the United States – whether the medical provider is within or out of Ametros’ medical network. Ametros’ medical network partners offer the upside of potential discounts; Ametros’ members are, however, free to choose their own providers or pharmacies. Ametros members can inquire with Ametros about providers being in or out of the network. The majority of Ametros members choose to utilize Ametros’ medical network partners’ discounted rates to save money on their treatments. Members can elect to opt-out at any time from the application of medical network discounts on bills for their account and Ametros will not process their bills through its medical network partners. If the member chooses to opt-out of receiving medical networks discounts, it means, unfortunately, the member will not capture any network savings on their account because discounts are not being processed and applied. For recipients of workers’ compensation settlements who seek provider treatments, regardless of whether the provider is in the network or out of the network, Ametros is often able to apply the workers’ compensation state fee schedule discount to the bill.

Please be advised Ametros utilizes the following Pharmacy Benefits Management (PBM) and Durable Medical Equipment (DME) partners in the delivery of services to its Members, and Ametros may receive compensation in the course of providing services. Members may opt out of using these partners.

Ametros’ PBM Partners: Pharmacy Data Management, Inc., Change Healthcare Solutions, LLC, RX Sense, LLC, PharmaPix International, and Capital Rx.

Ametros’ DME Partners: Eaze Medical Solutions, VGM Group, Inc. dba Homelink, Incingo Source, Management, LLC.

For more information, please refer to https://ametros.com/notice/.

While Ametros’ medical network partners have relationships with a vast network of physicians throughout the country, it is important to note no providers or facilities are mandated to accept patients that have accounts with Ametros. In fact, no private physician or provider is mandated to accept patients for any insurance coverage (Medicare, Medicaid, Workers’ Compensation, or Group Health) and sometimes they are not accepting new patients altogether. This means at any time a provider or facility may decide to decline seeing the patient or accepting the negotiated discounted rate that is being proposed. Ametros’ billing team does its best to convince providers and facilities to accept payments from Ametros at discounted rates and has good success in doing so, but there is no guarantee these efforts will always be successful. On the other hand, if the physician or provider will accept direct payment from the member, as long as it is an eligible use of the account, the member can pay directly and be reimbursed from their account. Also, the member is welcome to seek treatment from any provider or facility in the country, so the member may also be able to find a provider willing to accept direct payment from Ametros at a discounted rate.

Ametros makes best reasonable efforts to ensure the Ametros medical network price is not higher than what the member would have otherwise paid if they were a cash-payer who paid the retail price. Ametros cannot guarantee the pricing it secures for treatment, prescriptions or medical items will be the lowest possible pricing available anywhere in the market. While Ametros secures discounts on many medical treatments and prescriptions, it is not always possible for Ametros to beat or match other rates that may be available through other discount programs or direct negotiations. It’s important to note if the member believes they can secure better pricing through another method, they are free to negotiate directly or pay out-of-pocket and be reimbursed from their managed account, assuming it is for a treatment that would be an allowed use of settlement funds. While many times Ametros finds the best deal, if the member has a better one, they are able to use it.

For CareGuard, the funds must be placed in a custodial account with specific Ametros partner banks. However, for Amethyst the funds can be placed in an account with any bank of the member’s choosing.

For Ametros’ professional administration service, CareGuard, the medical funds must be placed in a custodial checking account at an Ametros banking partner. This is because Ametros has built sophisticated technology integrations with these banks that allow the automatic deposit and disbursement of funds as well as transaction validation on professionally administered accounts. This makes the process immediate and thoroughly verified for safety, security, and accuracy.

As noted above, Ametros’ self-administration service, Amethyst, allows the member to place their medical funds with any bank. To establish an Amethyst account, the member simply needs to provide the debit card information for the account where the funds were deposited and can easily sign up online.

No. In CareGuard, Ametros places all funds in separate, interest-bearing checking accounts that are individually insured by the Federal Deposit Insurance Corporation (FDIC) up to $250,000. For more information on FDIC insurance see: https://www.fdic.gov/deposit/deposits/faq.html. The funds are not placed into any investment vehicles and are not at risk of investment losses. More information on Ametros’ accounts and their security is available here: https://ametros.com/security/.

In Amethyst, the individual can place the funds in any bank or account they wish.

Frequently in workers compensation and liability settlements there is a provision in the settlement agreement that governs the person(s) or entity(ies) (the “beneficiary(ies)”) that will receive what remains of the medical settlement funds in an administered account upon the death of the injured person. The parties to the settlement on both the plaintiff and defense side may negotiate this provision and place certain stipulations on how the remaining funds are disbursed. Upon death of the account holder, Ametros reviews these terms in the settlement agreement and disburses funds to the beneficiary(ies) that are named. If there is no beneficiary named, the funds will pass on to the account holder’s estate or according to their will. If there is no beneficiary(ies) named in the settlement agreement, nor an estate plan or will, the member can fill out a beneficiary form with Ametros. For clarity, any instructions in the executed settlement agreement always take priority in governing the disbursement. Regardless of the beneficiary(ies), Ametros does not retain any of the remaining funds in the account.

No. Ametros does not keep any remaining balance in the account nor does Ametros charge a fee for closing the account and making disbursements to the appropriate beneficiaries.

The Medicare Set-Aside regulations require that funds in a Medicare Set-Aside account can only be used to pay for medical treatment that is related to the injury that gave rise to the settlement. Ametros’ technology identifies treatment commonly associated with applicable injury/ies to ensure prompt payment is processed. If the injured party believes a medical treatment is related to the injury that gave rise to the settlement and it is not readily apparent from the medical claim (for example, a lower back injury that is now impacting the foot), Ametros requests documentation from the member’s treating provider associating the treatment. Ametros relies on the injured party’s treating physician to clarify any questions regarding injury relatedness as is recommended in CMS’ WCMSA self-administration toolkit. Ametros documents the member’s file with the treating provider’s documentation should CMS or any other entity ever request information on whether the treatment was related to the injury/ies. This process ensures the ultimate decision on injury relatedness has input from a licensed, third-party medical provider. The member is free to seek treatment with any licensed provider in the United States for as many reviews or opinions as they would like.

CMS provides guidelines in its Workers Compensation Medicare Set Aside (WCMSA) Reference Guide and Self-Administration Toolkit relative to what is covered for a Medicare Set Aside (“MSA”). Essentially, treatments which would be otherwise covered by Medicare and that are related to the injury are eligible to be paid for from the account. If Medicare covers the treatment and it is related to the underlying injury/ies, then it can be paid for from the account. Ametros assesses what is covered by Medicare by accessing databases that store Medicare’s coverage rules. If information about what treatments Medicare covers is not clear to the member, the Ametros team provides the Medicare coverage guidelines to the member and offers to connect the member with a Medicare representative for clarification. As an added benefit, Ametros also seeks to find alternative items/services that are Medicare-covered which may treat the applicable condition as a substitute for items that were not covered.

CMS has designed drug management programs that are meant to help patients who are at risk for prescription drug abuse. Ametros follows the recommendations provided by these programs by providing notices to the patient, the pharmacist and the doctor in order to ensure these prescriptions are being taken safely. Ametros does not limit coverage or the use of medications based upon these guidelines, but only provides the recommended notices so that the patient, doctor and pharmacy can make informed choices about the member’s care.

For background, in 2019, CMS updated Section 17.1 of its WCMSA guidelines which indicates:

“CMS highly recommends professional administration where a claimant is taking controlled substances that CMS determines are “frequently abused drugs” according to CMS’ Part D Drug Utilization Review (DUR) policy. That policy and supporting information are available on the web at” https://cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/RxUtilization.html

Additional information on these programs is available at the link above.

Many other administrators charge upfront setup fees as well as ongoing annual fees to cover the costs of administering post-settlement medical funds. These fees can add up over time to sometimes be tens of thousands of dollars over the injured person’s lifetime.

Several years ago, Ametros eliminated charging ongoing annual administration fees for its services. Today, Ametros offers its products at the following prices:

• Professional administration service, CareGuard, has a one-time charge of $1,000.
• Self-administration service, Amethyst, has a one-time charge of $250.

Ametros has invested substantially in its people, technology, systems and processes to be more efficient and to improve its ability to automate many of its repetitive functions. This allows each of Ametros’ employees to be more productive and grants them the ability to focus more time on serving our members so we can provide a better experience while also managing our costs. This enables us to pass on lower administration fees. In addition, as Ametros has grown and added more members, it has been able to more effectively leverage the collective purchasing power of our member base. This has resulted in Ametros developing partnerships with affiliates such as banks and medical networks who appreciate and value the growing membership. These partners share revenue and provide placement fees to Ametros in exchange for providing services to our members. The net positive outcome for all parties results in Ametros’ services being offered at more affordable prices. Moreover, Ametros’ members have the potential benefit from access to professional services, competitive banking rates and medical discounts they otherwise might not have had.

Ametros makes money in three ways:

1. A one-time fee for establishing the account. This fee is charged once an injured person (known as a “member”) agrees to become an Ametros member and is a flat one-time charge regardless of the case value. This charge covers Ametros’ costs to establish the account and onboard the member onto our platform. Among other things, it covers Ametros’ time and potential travel for providing consultations (either telephonic or in-person), preparing and editing member agreements, gathering all the medical and settlement information, and properly setting up the account so Ametros can administer the ongoing needs of the member. The law does not regulate who pays this fee, but it is often paid for by the insurance carrier or employer. However, other times it is paid for by the member, the attorney or other parties.
2. Revenue from banking partners for placing deposits with them. Ametros ensures its members receive interest on their funds held in a CareGuard account. The interest rate provided may change at any time. Ametros banking partners target offering an interest rate within 0.25% of the national average for a checking account as tracked and reported publicly by the Federal Deposit Insurance Corporation (FDIC). The FDIC is an agency created to provide insurance and coverage for banking deposits for U.S. depository institutions. After a case settles, members’ funds are placed in separate, interest-bearing checking accounts with Ametros’ banking partners. These funds are FDIC-insured up to $250,000 per account (this is the maximum national insured amount for any individual opening a bank account). The funds are not invested in the stock market or other securities that have risk. In return for bringing the banks these deposits, Ametros’ banking partners pay Ametros a recurring placement fee for the funds placed with them. To learn more about the interest rate provided and the national average as published by the FDIC, see the rate disclosures section of this document.
3. Revenue from medical network partners for processing bills through their networks. Ametros’ systems and network partners are in place to make the best reasonable efforts to ensure its members receive pricing for a treatment or item that puts them on par or better off than they would have otherwise paid if they simply paid cash to the provider or pharmacy for their listed and publicly available retail price. Ametros has invested significant resources to build technology and processes to interface with multiple medical network partners who specialize in negotiating and facilitating discounts with providers, pharmacies, equipment suppliers, transportation, etc., and Ametros works with these partners to provide medical claims processing solutions and savings for its members. In turn, Ametros earns a revenue share from its network partners only in instances when bills are discounted. To learn more about the discounts Ametros secures for its members see the rate disclosures section.

The current annual interest rate that is paid to members on their Ametros CareGuard account is within 25 basis points (0.25%) of the national annual interest rate average for a non-jumbo checking account as tracked by the FDIC. The current annual interest rate offered on a CareGuard account is 0.07%. The rate is subject to change at any time. Ametros reviews the rate to benchmark it to the FDIC national average for a checking account for a non-jumbo account (holding less than $100,000). The national average information is available here: https://www.fdic.gov/regulations/resources/rates/

In Amethyst, the member places their settlement funds in a bank of their own choosing, and the interest rate will be dictated by that bank.

The healthcare provider and facility billing process is complex as there are many factors influencing prices and rates. Discounts on provider and facility bills can vary widely based on the type of treatment, the coding of the treatment, the provider/facility and location, among other things. Ametros’ claims team and technology audit each bill and sometimes identify coding mistakes or redundant line items that can be eliminated. This can result in substantial savings for the member.

While Ametros’ services can often provide significant savings on provider or facility bills, this savings is not guaranteed. sometimes a provider or facility may opt to decline to see the patient or to decline the negotiated discounted rate that is being proposed, though Ametros team will contact them to provide support. For workers’ compensation settlements, Ametros can often allow the member to pay the state workers’ compensation fee schedule rate for the treatment. These rates can be a significant discount over standard billed charges. For settlements associated with other insurance coverage types, Ametros can often provide considerable discounts from the billed charge. Ametros makes no guarantee of specific savings rates to its members. Ametros’ past performance is no guarantee of future results. See https://ametros.com/ametros-terms-and-conditions/

Discounts can vary widely on durable medical equipment and ancillary services based on the type of equipment/service, customization, location of delivery, etc. Savings can range from little to no savings at all to sometimes 30% or more off the retail list price. Ametros medical network includes various equipment providers and companies who specialize in products and services that are often used by our members. For equipment orders or services, members may request Ametros’ team secure a quote so they have an idea of the cost before ordering. Ametros makes no guarantee of specific savings rates to its members. If a member has a question about their equipment or other services or products, they are welcome to request an estimate from Ametros. The estimate is not a guarantee of what price Ametros can secure.

Ametros’ past performance is no guarantee of future results. See https://ametros.com/ametros-terms-and-conditions/

Discounts can vary widely for medications based on whether the prescription is brand or generic and other factors which may affect costs, include dosage, quantity, manufacturer, and pharmacy provider. Savings may range from little to no discount at all to as high as 80% off the retail list price. Ametros makes no guarantee of specific savings rates to its members. If a member has a medication pricing question, they are welcome to request a free estimate from Ametros. The estimate will not be a guarantee of what Ametros can secure. See https://ametros.com/ametros-terms-and-conditions/

Ametros ensures the member will not pay more for their prescription medication at the retail pharmacy than they otherwise would have paid according to the pharmacy’s appropriately reported “usual and customary” retail/cash rate provided to Ametros. Ametros partners with pharmacy benefit management companies to negotiate rates with pharmacies and to gather the reported “usual and customary” cost which is what the retail pharmacy reports it is charging a walk-in, cash-paying customer with no coupons, discount codes, loyalty, membership, or other programs that provide special discounts. Ametros cannot ensure its pricing through CareGuard will always match pricing obtained through any discount programs other than CareGuard. Ametros’ past performance is no guarantee of future results. See https://ametros.com/ametros-terms-and-conditions/.

No. Ametros is continually trying to find ways to save its members money and the market is constantly changing. From time to time, Ametros may publish figures regarding savings on historical treatments. These figures are in no way a guarantee or indication of future results. Ametros’ past performance is no guarantee of future results. See https://ametros.com/ametros-terms-and-conditions/.

Ametros’ goal is to offer great value to our members at affordable prices so that our services can aid injured individuals better manage their settlement funds, and to live happier, healthier, and more productive lives. Ametros is committed to being a forward-thinking, transparent and responsible industry leader.

If you have questions about Ametros or our services, please contact us.