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The Life Care Planner:
Interview with Janice Skiljo Haris, RN
by Marjory Harris, Esq.
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In a continuing series
featuring medical professionals in the workers’ compensation
system, Marjory Harris interviews Janice Skiljo Haris,
RN, MS, a Certified Nurse Life Care Planner and Medicare
Set-Aside Consultant who is CEO of MEDLink, a scheduling
and practice management service for Qualified Medical Evaluations
(QMEs), Agreed Medical Evaluations (AMEs*), and Independent
Medical Evaluations (IMEs).
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HARRIS: Janice,
you wear many hats and have a varied background in nursing
and the workers’ compensation system. One of your areas
of expertise is “Certified Nurse Life Care Planner
(CNLCP).” How does a nurse become a life care planner?
HARIS: As MEDLink’s
CEO since 1992, we schedule appointments and provide
practice management for 30+ medical-legal physicians
in California for workers’ compensation, fitness-for-duty,
retirement disability, long-term disability, and personal
injury. Our specialty services include Life Care Plans
and Medicare Set-Asides. Our extensive physician list
can be found at www.camedlink.com
As a CNLCP since 2004, I meet the professional criteria set
forth by the national CNLCP™ Certification Board in
that I am a licensed Registered Nurse for over 30 years;
completed a minimum of 120 continuing nursing education units
in case management, life care planning and/or expert witness
approved by the Certification Board; demonstrated 4,000 hours
of case management experience or the equivalent in the continuum
of care; and passed the CNCLP certification examination.
As a Medicare Set-Aside Consultant Certified (MSCC) since
2005, I meet the professional criteria set forth by CHCC
for candidates to include completion of 30 hours of training
related to Medicare Secondary payer (MSP) compliance and
passed the MSCC examination.
Thereafter, the CNLCP and MSCC are required to demonstrate
completion of ongoing continuing education in each respective
field. |
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HARRIS: As
a Certified Nurse Life Care Planner (CNLCP), what process
or methodology do you follow?
HARIS: The emerging
field of CNLCP includes a specialized subset of medical
life care planning that deals with catastrophic injury,
personal injury, and chronic illness. The CNLCP uses
the nursing process to evaluate current needs, and
project future needs of individuals with chronic illness
or catastrophic injuries in order to ensure optimum
lifetime quality of care. The CNLCP uses a systematic
method of assessing, identifying, and quantifying with
a Plan the multidimensional disability related needs
of an individual. The Life Care Plan documents and
summarizes the required treatment over the lifetime,
including surgeries, therapy, medicine, assistive devices,
home modifications, and other care issues, and the
estimated cost. Projecting the future medical and nonmedical
needs of an individual helps ensure funds will be available
to provide for lifetime medical and non-medical care.
The Medicare Set-Aside (MSA) process also includes certain
aspects of the Life Care Plan as above but its focus is to
identify the Medicare covered versus non-Medicare covered
medical allocations and costs for those claimants who meet
Medicare’s threshold criteria. Medicare requires that
its interests are considered in all settlements, and with
the inclusion of the MMSEA Mandatory Insurance Reporting
in 2010, this will include workers’ compensation, liability,
no fault, and self-insured. However, to date, Medicare only
recommends a formal MSA for its approval when the threshold
criteria are met.
Both the LCP and MSA serve as the basis of settlements including
structures that provide for payments over time to cover medical
costs.
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“The emerging field
of CNLCP includes a specialized subset of medical life care
planning that deals with catastrophic injury, personal injury,
and chronic illness.”
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HARRIS: Who
generally retains your services, defendants or applicants’ attorneys
or both?
HARIS: As a Certified
Nurse Life Care Planner (CNLCP) and Medicare Set-aside
Consultant Certified (MSCC), I provide formal LCP or
MSA analysis for court and Medicare approval as well
as informal analysis for settlement planning. My CNLCP
and MSCC practice over the past 5 years has included
independent consultation by either the defense or plaintiff,
as well as mutual approval by both sides. In my experience,
generally the carrier reimburses the full MSA and LCP. |
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“In my experience,
generally the carrier reimburses the full MSA and LCP.”
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HARRIS: When
an attorney reviews a life care plan, what should we be looking
for? Are there any “red flags” we should notice?
HARIS: For the
opposing life care plan, there are several red flags
to consider. Did the life care planner consider all
the medical records and consider the medical and non-medical
life care needs? Have the medical care allocations
been supported by the records and reasonable medical
necessity? Did the life care planner consider complications
and long-term care needs for an aging claimant (i.e.
claimant who has suffered a SCI [spinal cord injury])?
Is there a basis for the life expectancy or rated age?
If the claimant is Medicare eligible, does the LCP
include Medicare and non-Medicare services and costs?
Are the medical and non-medical life care costs supported
by valid codes and state cost references? If usual
and customary manual costs are provided, are they supported?
Did the LCP incorporate appropriate life care planning
methodology and clinical practice standards in the
analysis? For the MSA, is the allocator familiar and
current with Medicare covered services?
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HARRIS: Our
forensic evaluators are often quite vague about future medical
treatment and medications. When doing the life care plan,
what resources do you use to determine what is needed and
what it costs? Also, how does one evaluate the Medicare Part
D 'doughnut hole’ for prescription medication costs
in the MSA?
HARIS: With
regard to the future medical care allocations, the
specific type, frequency, and duration of medical services
or drugs are often ill defined. The CNLCP should consider
the entire claim to include the pattern of prior medical
treatment provided per the medical records, the future
medical recommendations by the primary treating physician
(PTP) and forensic evaluators, the evidence based medicine
guidelines, and the nursing process in the continuum
of life care. Methods to identify and quantifying the
allocations should consider the PTP, the medical-legal
specialists, utilization review, pharmacy, carrier
payments, and the claimant.
For the LCP, there are a variety of pricing methods that
should be considered. These include but are not limited to
the workers’ compensation state fee schedule, and usual
and customary non-industrial medical/surgical treatment fees
per geographic regional areas. As a NLCP, I usually set forth
a range of fees to allow the parties a basis for comparison
in settlement.
For the Workers’ Compensation MSA, medical treatment
prices are set forth by the state fee schedule. As of 06/01/2009,
however, Medicare CMS began independently pricing future
prescription drugs in the WCMSA per the CMS Memo 04/03/2009.
The CMS directive bases the drug calculations on the average
wholesale price (AWP) and will not recognize any other pricing,
discounts or calculation methods. This means that the prior
strategy to reduce medication costs in the MSA using the
Medicare Part D ‘donut hole’ is obsolete. Additionally,
CMS will default to using the AWP of the brand name medication
if CMS finds that a WCMSA erroneously omits a future prescription
drug. For pricing, CMS recommends using the RED BOOK, a nationally
recognized reference for AWP drug pricing. While CMS accepts
drug pricing using generic substitution, CMS will not recognize
the generic pricing of future prescription drugs if a generic
brand is not available at the time of the submission of the
MSA.
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See "Structured
Settlements: The Whole Truth About the Doughnut Hole"
"The CNLCP should consider the entire claim to include the
pattern of prior medical treatment provided per the medical
records, the future medical recommendations by the primary
treating physician (PTP) and forensic evaluators, the evidence
based medicine guidelines, and the nursing process in the continuum
of life care.”
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HARRIS: What
does a life care plan typically cost?
HARIS: Pricing
for a Life Care Plan depends on the type of case. A
LCP for claims involving a catastrophic trauma such
as a traumatic brain injury (TBI) or spinal cord injury
(SCI) would require a home assessment, voluminous record
review, and substantial research analysis to set forth
future allocations and costs. A chronic pain LCP second
to failed back fusion with high permanent disability
may not be so time intensive. Certainly, a brief Medical
Care Cost Analysis for settlement planning would be
the least expensive. An MSA Analysis is usually a flat
fee.
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HARRIS: Is
there any conflict of interest in your ethical duties as
a CNLCP when you are employed by the defendant? How do you
strike a balance between providing patient care and keeping
costs low for the insurer or employer?
HARIS: As the
CEO of MEDLink, I am fortunate to have exposure to
several industry respected medical-legal mentors -
such as orthopedic surgeons Stephen Conrad, M.D. and
Alfredo Fernandez, M.D., as well as psychiatrists Gordon
Baumbacher, M.D. and Damon Walcott, M.D. - who have
influenced my personal challenge to provide equitable
determinations in the life care planning process. Furthermore,
I believe that professional responsibility, and ethical
considerations should prevail over politicization,
so that, what is medically necessary and reasonable
will prevail.
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“I believe that professional
responsibility, and ethical considerations should prevail over
politicization, so that, what is medically necessary and reasonable
will prevail.”
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HARRIS: We
usually only see a nurse life care planner in catastrophic
cases, where instead of leaving medical open, the parties
are contemplating a structured settlement with a Medicare
Set-Aside (MSA). But we all have cases with fairly complex
medical needs, such as future knee replacements or long term
care for Complex Regional Pain Syndrome, where we are at
a loss to figure out the real future medical treatment costs.
The MSA analyses we see only assess the costs of items mentioned
in the forensic reports, and leave out other costs which
are addressed in the life care plan. Do you have any advice
for the applicant’s attorney on how to figure out the
costs, if they cannot afford a formal life care plan?
HARIS: A cost-saving
option for the plaintiff attorney would be a brief
Medical Care Cost Analysis for settlement planning.
A full MSA Analysis is usually a higher flat fee. Of
course, the LCP involves the highest fee. MEDLink pricing
for these services can be obtained by calling (415)
399-9769 or by email at camedlink@camedlink.com.
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A cost-saving option for
the plaintiff attorney would be a brief Medical Care Cost Analysis
for settlement planning.
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HARRIS: If
you could change the current landscape of workers’ compensation
medical treatment and create the ideal treatment environment,
what would it look like?
HARIS: Thank
you for such an ambitious question but the discussion
is such that it would take another interview. For now,
my hope for the injured claimant is that the necessary
medical treatment is actually provided by qualified
medical practitioners and that the future medical care
will be properly allocated for the injured claimant’s
lifetime.
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Janice Skiljo Haris, RN, MS CNLCP MSCC is the CEO of MEDLink.
MEDLink
1613 Montgomery Street
San Francisco, CA 94111
Phone (415) 399-9769 x221
jharis@camedlink.com
www.camedlink.com
*Advertising Disclaimer: The use
of the term "AME" refers to past use of MEDLink
doctors in that capacity at the request of referring
parties in the community. Per applicable California Labor
Code and Regulatory provisions, there is no claim or
representation that any MEDLink doctor has an ongoing
appointment as an AME.
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