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The Life Care Planner:

Interview with Janice Skiljo Haris, RN
by Marjory Harris, Esq.

> Calculating FMT
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> Life Care Planner
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> Age as a Factor
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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).
 
 
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.
 
 
 
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.
 
“The emerging field of CNLCP includes a specialized subset of medical life care planning that deals with catastrophic injury, personal injury, and chronic illness.”
 
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.
 
“In my experience, generally the carrier reimburses the full MSA and LCP.”
 
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?
 

 
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.

 
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.”
 
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.
   
 
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.
 
“I believe that professional responsibility, and ethical considerations should prevail over politicization, so that, what is medically necessary and reasonable will prevail.”
 
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.
 
A cost-saving option for the plaintiff attorney would be a brief Medical Care Cost Analysis for settlement planning.
 
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.
   
 
 

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.

 
For a detailed CV, click here.