Medical cost projections come in all shapes and sizes, some portraying valid content while others showcase invalid projections that do not stand up well to an insurance company or a jury.
Why is there such a big discrepancy in the validity of medical cost projections?
The short answer is that each life care planner has their own methodology for how they construct the report. This leads us to the next question, “how do you know what differentiates a valid medical cost projection from an invalid one?”
Here are some tips to help you decipher possible red flags that may come up in the medical cost projections that come across your desk.
- Utilizing non-credible costing databases: If the costing database sources used are not nationally recognized databases, they are biased and do not provide accurate billing / coding information. Some companies use “their own” costing databases that only they are privy to using. This creates a bias when constructing the report.
- Utilizing “treatment trends” when costing: Many costing specialists will rely on what the treatment trend has been over the last few years for a particular service in order to justify what is needed for a patient’s future care. Here is an example: Let’s say that the patient underwent follow-up appointments with their pain management physician four times per year for the last three years but they haven’t seen the physician in over a year. Some cost specialists will extrapolate out physician visits four times per year through life expectancy as a “treatment trend” even though the patient hasn’t actually seen that physician in quite some time. A phone call to the physician is critical to see if there is a continued need for those follow up visits.
- Overreaching to pad the costs of the cost projection: Often times you will see extraneous items that have been recommended and costed out by the life care planner that may not be a necessity for future care. You might also see additional treatments that the client does not want solely to add to the amount of future costs. Here is a common example: Adding in a gym membership through life expectancy to a client that needs this care but has told you that they will never use this. Maybe pool therapy or a stationary bicycle in their home would be more suitable especially if a client voices that they would use it over a gym membership. Future costs must be justified, and if they aren’t, it leaves the life care plan open to speculation.
- Opining on items that are outside the life care planner’s scope of practice: Oftentimes future items and costs are thrown into a medical cost projection that the life care planner cannot opine on due to their scope of practice. For example, a nurse life care planner is not able to opine on the future frequency and duration of physical therapy because that is out of the scope of their practice. Life care planners can get into hot water if they are adding in future treatment and costs that are out of the scope of their practice and therefore are unable to opine on these items themselves. Again, a call to the treating physical therapist is warranted to make sure the items that go into the cost projection are accurate.
Medical cost projections are designed to follow the same methodology of a life care plan. The main difference is that medical cost projections are typically drafted for non-catastrophic injuries and life care plans service catastrophic injuries. Both reports should provide the reader with a clear and identifiable pathway to understand what their client’s future care needs are and the costs associated with them.
Remember, the more ambiguous the report, the more susceptible the report is to failing Daubert and Frye standards. Make sure you hire a credible and expert life care planner for your life care plans and medical costs projection needs. The expert must also understand impairments / disabilities and personal injury cases in order to fully understand the needs of the client.
Dr. Poppie has served the legal industry as a treating clinician, damages expert, and educator for over 20 years. He specializes in the evaluation and treatment of multi-trauma injuries related to motor vehicle collisions, standard of care and malpractice claims, and as a damages expert to help educate insurance companies and both plaintiff and defense counsel to provide a viable pathway for obtaining a fair settlement based on ethics, research, and evidence-based standards of care.
Dr. Poppie founded Injury Reporting Consultants to help attorneys and insurance companies resolve personal injury cases through medical analysis and reporting. Injury Reporting Consultants is a collaborative team of dedicated medical professionals using their knowledge to ensure fair outcomes for all parties in personal injury cases.
Recognized specialties include Motor Vehicle Collision, Life Care Planning, Medical Cost Projection, Functional Capacity Evaluation, Onsite Job Analysis, Functional Impairment and Disability, Workplace Injuries, Orthopedic Physical Therapy, Standards of Care, Current Best Practices, Physical Therapy Malpractice, Negligence, File and Medical Record Review, Improper Documentation, Expert Rebuttal Reports, and Expert Testimony.
If you have a client that you would like to discuss their need for an expert report, please contact me directly at 720-982-2000 or email me at: firstname.lastname@example.org
Learn more at Dr. Poppie’s educational videos!