Projecting Costs: the Larger Picture

When it’s time to factor future medical costs, a common concern is that the projection may be insufficient to meet a patient’s needs. The strong temptation is to include all potential complications, and choose the highest-end durable medical equipment. However, this is rarely the best approach to meeting that patient’s needs. The resulting exorbitant projection may result in rejection of an otherwise reasonable settlement.

Professionals may confuse Life Care Plans with Medical Cost Projections:

A Medical Cost Projection, or MCP, is confined to reviewing medical records and projecting the costs of a specific surgical procedure or medical course of care. Some of those costs are projected for the lifetime of the patient, or the weeks remaining on a worker’s compensation claim.

Performing a Medical Cost Projection does not require professional certification and although classes are available, many MCPs are constructed by individuals who seek guidance from peers.

MCP’s are factored by geographic adjustment, reimbursement by private insurance or state Board fee schedules, and vary in quality and accuracy depending upon the contractor’s experience.
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A Life Care Plan, or LCP, does require certification since these plans are often associated with depositions and testimony at trial. When a patient has a catastrophic injury or illness, the plan may involve a visit to the patient’s home, interdisciplinary communication, coordination, and anticipation of lifelong healthcare needs.

Life Care Plans are based upon actual charges and are not limited by the concept of reimbursement. The plans require a careful assessment of the patient’s lifetime needs, family resources, community and educational support, medical supplies, and potential complications.

In predicting future complications, Nurse Life Care Planners have the advantage.

In the hospital setting, nurses oversee every aspect of patient care and coordinate scheduling among respiratory, physical, occupational and speech therapies, dietary consults, and diagnostic procedures. Certified Nurse Life Care Planners are attuned to the patient’s need for and response to medication, the status of their hydration, mentation, skin integrity, and early signs of complications. Our experience and utilization of nursing diagnoses guide us in prevention and management.

While physician diagnoses support the need for medical care and shape the bones of an LCP, nursing diagnoses, of which there are 250, flesh out a life care plan. A nurse with experience in burn care, TBI, cerebral palsy, amputations or the elderly, knows what constitutes a preventable complication. Our plan recommendations align with nursing diagnoses and our only boundaries are those established by the Nurse Practice Act of our state.

But whether a Life Care Plan is constructed by a nurse, social worker, counselor or rehab supplier, the goal remains the same: planning and funding for care that will maximize the patient’s potential for independence while adding to the quality of their remaining years.

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The Changing Face of Body Language

As the daughter of an Army Drill Sergeant, I grew up around Fort Jackson, SC. We shopped at the PX, attended the Roman Catholic church on base, bought 29 cent gasoline and went to the movies for a …

Source: The Changing Face of Body Language

You thought this case had merit

Every law firm has a unique philosophy that guides them in their decision to represent a plaintiff or plaintiff’s estate. With that in mind, if a case is turned down, it is always for a good reason that applies to that particular firm. Most attorneys want to clearly explain reasons for denial in layman’s terms with the potential client.  No firm wants to be sued for professional negligence, so part of the explanation will emphasize that the plaintiff or family are free to seek a second legal opinion.

If you are asked to review medical records so that the attorney can determine the merits of a potential case, keep these points in mind:

  • The medical facts were not compelling during the initial review, or perhaps were not “facts”.
  • The firm does not handle this type of case – be certain you have a good understanding of the firm’s preferred specialty area
  • The case has merit but will require more money and resources than the firm can apportion
  • The firm handles high value cases referred to them by smaller firms who find merit, but cannot afford the cost of experts, records, depositions, etc.
  • The medical injury is a high-risk surgery or other event with known complications that are difficult to define as negligent
  • The permanent damages are minimal – the patient feels that past expenses support the severity of damages but in truth, future loss and costs determine the ultimate value

Know the firm’s philosophy, preferred type of work, tolerance for financial risk, and most importantly, the attorney’s first-brush legal opinion of the case. That opinion, more often than not, is accurate.

Authenticity

I believe the greatest barrier/challenge that faces a new LNC is the ability to manage anxiety in new situations, meetings, presentations or interviews with attorneys.

These are the same problems faced by attorneys in preparing a closing argument.

When I began meeting new attorneys, I know that I did not project self-confidence. I will always be grateful for the ones who hired me despite this shortcoming. I was not convinced of my worth or that I could provide what they needed. I knew the lingo and had read the bullet list of 30 benefits of hiring a legal nurse, but I had not yet delivered those benefits.

I grappled for words that would communicate my competence in case analysis, but I was relying upon the success of others to give me courage.

Amy Cuddy is a social psychologist with a fascinating story (find her on TED talks and read her book, “Presence”). She combines multiple philosophies and her own experience to describe that hard-to-capture essence of convincing others that you are worthy.

Convincing others of your worth begins with conviction that you have the qualities you wish to impart. When you truly believe in what you do and who you are, others will also believe. I know after ten years and many hundreds of cases from all sides of the law that I am who I say I am.

True authenticity is not memorized or rehearsed; it comes from the heart.

The Dependency Curve – Guest Post from Dr. David B. Adams

This Week’s Topic: “It’s Curvilenear”

Question: “He clings to me, then resents me, then begs me and then rages against me.”

Dr. Adams replies: ”We enter life entirely dependent aside from vegetative functions. We cannot exist on our own, and this characterizes most living species.

We oft-times terminate our existence by returning to that same position, reliant upon others for the same functions that we had learned to perform independently so many decades ago. It is the curvilinear shape of dependence.

We learn to ambulate, communicate and negotiate our world in stages and steps that enable us to function as separate beings, and, in turn, we then rear our offspring to do the same. This is how society exists and advances.

There are obstacles and trauma that require us to briefly regress to deal with illness and injury, loss and disappointment, but in all cases we return to that path of autonomy.

We marry and become interdependent. We allow others to manage most of our lives and become passive-dependent. We become addicted and co-dependent. We resent those upon whom we must rely and become hostile-dependent.

An injury may require an acute period of return to dependency. We call upon emergency medical services, rely upon primary care, must defer to hospital policies, and for the most part we become conditioned, helpless to the point that we cannot even remove our own sutures (sidebar: Unless you are married to a nurse, but that’s likely off-topic).

Injury becomes a struggle between the inherent need to be independent and the concurrent and often pressing requirement that we temporarily accept our dependent role. This will include passively accepting our providers, their schedules, their treatment approach, as well as the consistency/inconsistency of receipt of benefits. Since this most often is in sharp contrast to how we existed only seconds prior to injury, this is arguably the greatest trauma of all.

For some patients, dependency is a characterological flaw. It is a personality defect awaiting expression. It may have presented multiple times during the patient’s history, times to which we are not privy. But the chronically emotionally dependent patient becomes a challenge in case management.

Those assisting the chronically dependent patient become the target of neediness, resentment and fear. The role must remain clinical and, to some degree, sterile in order to address objective damages. The dependency may be emotionally catastrophic for some patients, but it is not often addressed during the course of injury care.

It is essential to recognize that the dependency arising after injury is either something that the patient finds aversive or something to which the patient too readily acclimates.

An injury can be catastrophic to the point of complete and permanent inability to attend to the Activities of Daily Living. In all other instances, the goal from the outset must be a return to whatever level of independence can be achieved. Thus, the inpatient healthcare team includes discharge planning and goals in their initial assessment upon admission.

Mediating with a Full Deck

It’s no secret that most civil cases never go to trial, or that insurers would be happy to settle workers comp cases rather than periodically increase their reserves. Unfortunately, it is also true that plaintiffs have no way of knowing how to value their claim or accept their attorney’s recommendation for a reasonable settlement. They drink the Kool-Aid of TV commercials, uninformed friends, and the back-end advice of their city bus.
More importantly, attorneys  have a difficult time knowing how to place a proper value on their client’s claim for future medical costs. Looking at past costs and lost wages is a cut and dried process. Asking colleagues for a ballpark figure on surgery, or going to a source like Healthbook, never takes into account the individual needs of client. And the client (patient) lives for the future.
Since mediation is often the final chance to intervene in an injured person’s life, make sure the potential costs are known, and presented in a professional format that facilitates acceptance at the table. Using the proper CPT codes, basing the cost on the State workers compensation fee schedules or the 75th percentile of UCR, including recent office visits, diagnoses and current life expectancies, creates a powerful tool for settlement.
Medical Cost Projections should be based upon the recommendations of the treating physician for potential surgery and medical care; annual costs of physical therapy, psychological care, x-rays, lab work, office visits, medications, DME equipment, bath and kitchen aids, yard and home maintenance if this will be an issue, and other costs that might occur with catastrophic injuries.
Big or small, every settlement matters to the patient whose life continues after both sides of the table go home, or on to the next case.

Maintaining the Veil of Anonymity

Just as new LNCs are feeling their way, so are new attorneys. And plaintiff counsel may not have a flexible budget until they have been in practice for a while.

Personal injury and med-mal attorneys who tell their clients that “they won’t pay unless their case is won” still have to cover expenses. Workers compensation attorneys must convince the injured worker that a body of work is important enough to warrant a portion of their settlement.  So even though a merit screen or a chronology is warranted, that attorney may worry that the client will not see the value in such services. After all, they expect the attorney to know if their case is viable.

On rare occasion, a new attorney may ask a nurse consultant to meet directly with a patient in case evaluation, and to accept payment for their service directly from the patient. This practice is not recommended for the independent nurse contractor.

I want my attorney to be comfortable, but I also know that my value resides in anonymity. When asked if I will accept payment from the patient directly, here is my reply.

I understand that you will pass this expense on to your client, but it is in both of our best interests to maintain a veil between me and your client.
1. An assessment for merit is a clinically objective appraisal.
2. Clients (as you know) are emotional and feel they must compel someone to agree with them.
3. My relationship as an independent contractor is with you – you are my client.
4. Merit may be in question because of inconsistencies in the client’s complaint, or because they are over-reaching, or because they equate malpractice with unforeseeable complications and mistakes. This is pivotal, but a hard pill to swallow.
5. My value to you is my invisibility because you are the principal – you are the person they want to hire – I am in the background.
6. My work product is always confidential and my opinion is withheld from experts, even when they use my objective chronology. I cannot control this process if I am accessible or responsible to anyone but you.

That said, I can write a short paragraph that explains exactly what I will be doing and why an experienced nurse should evaluate medical records.

If there is a question of merit and you decide not to take the case, I can craft a short and clear layman’s explanation of the medical injury/condition for you to incorporate into your response.

Please let me know if I can be of any assistance to you in this matter.

I look forward to a long working relationship with you.

All the best,