The Life Care Planning handbook mandates that “research information that the Life Care Planner has obtained should be readily available for review and reflected within the life care plan.” While many life care planners abide by this rule, some fall short. A well-constructed life care plan should identify the resources and data relied on to price goods and services in the market. Moreover, it should contain a description of the methodologies applied in the plan. The following article discusses some of the common problems seen in the vulnerable life care plans that are vulnerable to challenge.
Common Problems Identified in Life Care Plans
Where’s the Evidence?
Vulnerable life care plans are often loaded with duplicative services and pricing that is not supported by authoritative evidence or reference. Well, prepared plans use strong data and well-justified methodologies. By providing pricing based on market data, these life care plans establish a sound defense against criticism. When juries are asked to consider the strength of a plan in evidence, a plan with a demonstrably reasonable pricing methodology gains the greatest traction in court.
Vulnerable life care plans can seem arbitrary when not supported by data, such as pricing schedules, market research, claims data, and medical/billing records. Life care planners may see services performed in the medical records but when reframing those services in a plan, choose different billing codes with different values. For instance, the Current Procedural Terminology (CPT) code 99245, which is one of the most comprehensive codes used for evaluation and management services, is currently valued at $232.49 for non-facility (physician office) visits. CPT code 99215 represents a similar evaluation service but is a less complex code and resultantly is valued lower at $150.29 (non-facility) visits. A life care planner who fails to recognize the distinction may mistakenly over or under value the service identified. The medical and billing records should support any services suggested by the Life Care Planner.
Selecting a Pathway to Care
Many disabled individuals qualify for multiple types of care – i.e., facility care versus home health care. In torts cases, it is common for attorneys to advocate on behalf of their clients for the most comprehensive level care. However, doing so without understanding the significance can result in a claimant receiving care (coupled with associated costs) that does not fit the need. For that reason, life care plans that identify alternative options for care, such as facility care and home health care, should describe alternative options as separate and distinct paths of care within the plan.
Drug Pricing: Brand Name, Generic or OTC
A vulnerable life care plan may include brand-name versions of medications, which have a generic counterpart or may be purchased over-the-counter. While brand name medications are more expensive, the assumption that a physician visit is required adds additional cost to the plan. As a result, the total value of the life care plan is increased. On that account, life care plans should be constructed to consider whether the identified prescription drugs are covered by insurers.
Duplication of Services
On occasion, life care plans are created with duplicative items and services. The duplication can go unnoticed because the plans are lengthy and complex. To appear methodologically sound, some life care planners divide services according to the age and life expectancy, providing tiered options for the disabled individual across each age range. When multiple options are split into even more options (such as Skilled Rehabilitative Care v. Adult Day Health Care), multi-tier plans can lead to confusion.
Example: Life care planner (LCP) A prescribes 24 hours a day until life expectancy of Skilled Rehabilitative Care for individual X, who is currently five (5) years of age. LCP A also recommends that individual X be placed in an Adult Day Health Care program at age 21 to life expectancy.
The kind of care provided under each program overlaps and are somewhat duplicative. On one hand, Adult Day Health Care, as defined under federal regulations, is “… a therapeutic outpatient care program that provides medical services, rehabilitation, therapeutic activities, socialization, nutrition, and transportation services.”[i] On the other hand, Skilled Rehabilitative Care, as defined, includes “(1) Ongoing assessment of rehabilitation needs and potential: …; (2) Therapeutic exercises or activities: …; (3) Gait evaluation and training: …; (4) Range of motion exercises: …; (5) Maintenance therapy; …; (6) Ultrasound, short-wave, and microwave therapy treatment by a qualified physical therapist; …; (7) Hot pack, hydrocollator, infrared treatments, paraffin baths, and whirlpool; and (8) Services of a speech pathologist or audiologist when necessary for the restoration of function in speech or hearing.”[ii] Because each service is distinct from the other and applied to different age ranges, both may be interpreted as a different need. However, if the services are treated as overlapping from age 21 to life expectancy, then we will draw the wrong conclusion. Lengthy and complex care plans can result in unintended duplication substantially increasing the estimated value of care over time.
Substandard life care plans sometimes misidentify or improperly describe a modality sought by the claimant. For example, physical therapy is a rehabilitative service that is covered by most insurers. However, when described as a “recreational” or “stretching” exercise service, it is no longer covered. Essentially, the service of exercise and related equipment, though kin to physical therapy, are not covered benefits.
Questions to Consider
When reviewing the work of a life care planner, it is important to understand how each recommendation is impacted by insurance and collateral sources. Pricing a plan without considering those factors can lead to the development of a care plan for ‘sickness’ rather than ‘wellness’. Moreover, it opens the plan to a number of criticisms.
Below are questions to consider when reviewing the work of a life care planner:
- Did the life care planner consider the reasonable value of the items/services recommended?
- Was the pricing of items/services based on an established methodology?
- Are duplicative services listed in different areas of the life care plan?
- Is the life care plan clear and concise – i.e., easy for the layperson to understand?
- Did the life care planner rely on a consistent method for choosing CPT and HCPCS codes? (e.g., what unit of time was chosen and why?)
- Did the life care planner include items that are medically necessary in the care plan? (e.g., did the planner avoid the use of cosmetic items, brand name durable medical equipment, or uncovered items?)
- Were professional or academic pricing studies about medical procedures identified in the plan considered?
- Did the life care planner indicate whether he or she relied on the charged, billed, usual and customary, private or government rate to determine pricing?
[i] 38 CFR § 17.111
[ii] 42 CFR 409.33