Category Archives: LNC Skill Development

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.

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.

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,

LNCC and CLNC – what do these initials mean, really?

Attorneys are practical professionals. They seek a legal nurse who consistently delivers an excellent work product and sound opinions. They also recognize that certification should be an indicator of experience and expertise in a nurse. Although LNCC and CLNC are often thought of as interchangeable, even by some nurses, they are not synonymous.

Brace yourself for an onslaught of initials.

The LNCC (Legal Nurse Consultant Certified) is the only credential recognized by the Accreditation Board for Specialty Nursing Certification (ABSNC), formerly known as the ABNS Accreditation Council, which is the only accrediting body specifically for nursing certification.

The LNCC is obtained through the ALNCCB (American Legal Nurse Consultant Certification Board); see http://www.AALNC.org:

The LNCC® program is accredited by the Accreditation Board for Specialty Nursing Certification (ABSNC), formerly the American Board of Nursing Specialties (ABNS). ABSNC accreditation means that certification programs have met high standards for testing.

To be eligible to take the examination, candidates must have the following at the time of application:
• current licensure as a registered nurse in the United States or its territories, with a full and unrestricted license
• a minimum of five years of experience practicing as a registered nurse
• Evidence of 2000 hours of legal nurse consulting experience within the past five years.

Those who meet the eligibility criteria and successfully complete the examination will earn the Legal Nurse Consultant Certified (LNCC®) credential” (and must re-qualify by exam every five years).”

Note there is no mention of a specific “course” even though the AALNC does offer continuing education webinars throughout the year, various online courses, and other educational resources. However, their courses are not a prerequisite for taking the LNCC exam.

The LNCC credential is evidence of knowledge-based practice as well as broader knowledge of legal concepts in a wide range of settings from all medical-legal arenas. LNCC designation measures overall competency.

The CLNC designation is acquired through the Vickie Milazzo Institute; see http://www.legalnurse.com:

“2 Simple Prerequisites for Becoming a Certified Legal Nurse Consultant

1. Complete the Basic CLNC® Certification which is included in all 3 CLNC® Success Systems: VIP, Executive and Basic.
2. Maintain an active RN license in the U.S. or Canada. A BSN degree is NOT required.
Exemptions from meeting any of these criteria will not be granted.

Whichever CLNC® Success System you choose, you’ll receive everything you need to know to get started as a highly paid professional consultant – 100% guaranteed. Our Certified Legal Nurse Consultants are 25 to 75 years old and live all over the U.S. in both rural and urban areas. There’s no limit on succeeding as a Certified Legal Nurse Consultant.”

The CLNC program is six days, either in person or online, and offers supportive mentoring as new LNCs start their business. It provides a wealth of information, teaches new nurses how to initiate and self-promote their new business, obtain sample work products from a highly successful businesswoman/LNC/attorney, and many nurses credit the system with “jump starting” their business.

The CLNC credential is achieved after passing an exam of the materials presented during the six-day course. No experience as an LNC is required, and while the course is accredited for continuing education (as are many others); it is not an accredited certification through ABSNC.

Many CLNC graduates later achieve accreditation as an LNCC after proof of 2000 hours of legal nurse consulting.

There are a number of LNC courses accredited for continuing education, both online and through traditional colleges and universities.

But there is no substitute for experience.

What Your Attorney Needs from You

You should ask this question at the start of each new attorney-client relationship. I am not referring to the attorney’s area of specialization or their orientation towards defense or plaintiff work. I am speaking about their business and personal preferences, their personality, their desires. Despite having your own (no doubt strong) personality, you must adapt yourself to the communication and business style of the attorney.

I have a good rapport with some attorneys who like to share personal information and do not bother to begin and end emails with salutations. They encourage independent thought, brainstorming of theories; we have a mutually respectful and somewhat casual relationship.

There are also very formal attorneys, recognized immediately by their communication style. Respond to them in the same manner they address you. Begin your emails formally, pay close attention to your grammar and do not try to woo them with your witty asides. These attorneys may have a sense of humor but they do not know you well enough to share it.

Most attorneys have a very specific idea of what they need. They may want a detailed chronology and your personal opinion, but they will keep your opinion in-house. They may ask for a second chronology that does not have your name on the report, or your opinion in that optional column. You are their private resource and they need the opinions of experts to be based on clinical facts, not your intuition or experience. Your value is in your invisibility even though/because they are relying heavily upon you.

Some attorneys simply do not know what they want. They may have a case that falls outside their comfort zone. They may ask you how to proceed with experts, and dependently seek input. While this may be flattering, it is the trickiest case to manage because you cannot cross the line between nursing and the law. You are never responsible for their legal decision-making and you certainly don’t want to be responsible for the wrong opinion.

Be comfortable with yourself. Never accept demeaning or verbally abusive behavior even when putting your ego on the back shelf. This is a challenge for most nurses. We are an opinionated bunch and our opinion is what gives us value. Nonetheless, remember that no matter how close your affiliation with an attorney may become, it is first and foremost a business relationship. Their chief goal is to advise and satisfy their client. You will be most helpful if you ask them what kind of report, what kind of information, and what type of presentation they need from you. Then deliver a product that is unequivocal and fact-based, because the one thing all attorneys need is the truth.

How Much Time Does it Take to Create a Chronology?

How long does it take to compile a chronology from 5000 pages of medical records? It really does vary with each case. Sometimes a law firm will ask me not to produce a chronology with the goal of saving money; “just focus on xyz”. That is fine for an expert witness, but not for a legal nurse who is responsible for knowing about and explaining the medical issues of a case.  Invariably in a complex case, searching for a piece of data down the road or even later in the week will consume much more time than documenting it in the beginning.  This is true for pdf or paper records.

In medical malpractice, 5000 pages means hospital records and a range of healthcare provider data. Sometimes the sentinel event is clearly defined in a narrow time frame; healthcare prior to that point, while important to know, may be irrelevant to a wrongful death. When I receive a large paper case, the  first thing I do is heave it on the table and begin rapidly sorting into a stack that I know I will not need (but will keep), a stack that does not look important but may become so, and a stack that requires close scrutiny.

I work from the scrutiny pile in detail. Eventually, I will see a reference to something in my “maybe” stack so I return there to pull the page. By now, I have a feel for the case and will spot other important pages to pull. Every piece of paper that I reference in the chronology is retained in a new stack that is now taking shape. When all the data is entered, I sort it chronologically and read it again from a fresh perspective; chronological order makes it easier to identify missing records or redundant care.

I make a copy of that pertinent reference stack for the attorney. Oftentimes, my attorneys do not use or want Bates stamping unless it is mass tort (although it usually makes everyone’s job easier).  Either way, if they do not know the source of data, they or their paralegal will be wasting precious time trying to find it without this copy.

The chronology forms the basis of any research or articles that support, refute, or simply clarify my case.

Only then do I sit down and compose the report, which may only require a few hours initially. I always sleep on my report, re-read it the next morning and again later in the day. I then print it to see possible errors that were not evident on the computer. I repeatedly proof, determine that the ease of readability is appropriate and that the percentage of passive sentences is reasonable. I tweak it to death but I do not charge for this obsessive behavior – perfection is a relative term.

I present the data in a professional folder and off it goes, although the attorney may need the summary report immediately. If so, I protect the file so it cannot be altered and email it in advance.

From personal experience, the average time required to work up a case of this size is ~ 20 hours. The time may be more or less depending upon the event in question.  If the patient died in the first day or week of an event, it takes far less time to document than when tracking health changes over the course of time.

Large or small, the chronology is the basis for medical conclusions that may lay dormant for a year for legal reasons. A year down the road, everyone is grateful for this key document.