Life care plans
Using your in-house talent to write life care plans
for Medicare set-aside agreements can pay off

By John F. Marr
Senior Vice President, Claims
Maine Employers’ Mutual Insurance Company

Wendy Coyne, RN, CCM, CPUR, CNLCP
Unit Manager, Medical Coordinator Services
Maine Employers’ Mutual Insurance Company

By now, there’s hardly a person in the workers’ compensation business who hasn’t been confronted with the Medicare set-aside conundrum.

The fear of punitive damages in multiples of Medicare payments, due or pending, has caused quite a reaction within the comp industry. The intention of the Medicare Secondary Payer Act is indisputable, but the implications are the subject of ongoing debate.

For the past two or three decades, the workers’ compensation line of business has been a spawning ground for a number of businesses that like to help us with our work. It’s hard for a claim handler with less than 15 years’ experience to believe we could do our jobs without the assistance of a cadre of specialists. We have vocational specialists, medical coordination specialists, provider relationship specialists, etc. They all fill a niche and provide, without a doubt, a valuable service. However, they also challenge the expense factor despite the promise of a return on equity.

Now we have a new specialist—the life care planner. They have come into vogue because it is presumed the words of a credentialed individual will more likely satisfy the regulatory notions of the protectors of Medicare—the Center for Medicare and Medicaid Services.

The industry should not complain about CMS protecting the coffers of our government healthcare plans. They are right to prevent cost-shifting from workers’ compensation insurance to the feds. It also makes sense to develop a framework into which a rational plan can fit and an avoidance scheme be culled. This notwithstanding, the framework should neither be burdensome, time consuming nor expensive.

If you write business in a state which doesn’t allow for the commutation of future medical care, you’ve avoided a headache and can go on to the next article. However, if you happen to write in a state which allows future medical to be commuted, it’s another story. I suspect you’ve already been reaching for the aspirin to relieve your headache and the secret liniment to reduce the hip pain from pulling out your wallet.

Finding a simple solution—one that will limit the painful delay and expense—is practically impossible. Furthermore, the suggested remedies are as wide ranging as cures for the common cold. With that said, here’s one more solution: Take two aspirin, keep your wallet in your pocket and consider doing most life care planning in-house.

Tool in Medicare set-asides
Life care planning has been around for decades. It has been used in catastrophic liability claims and tort litigation to determine settlement amounts. It also has value in the effort to determine adequate reserves in larger cases. However, because of the Medicare secondary payer regulation, workers’ compensation carriers now are utilizing this tool in the development of Medicare set-aside agreements.

Writing a life care plan (LCP) is not high science. Opinions abound about the most appropriate person to write an LCP. Some feel any person who has had experience with injuries and rehabilitation can write such a plan. Others contend the best person is one with a medical background, such as a nurse or physician, who may better understand standards of care and the nuances of medical necessity.

Regardless of who writes the plan, it must be based upon sound medical standards and specific to the case in hand. A “cookie-cutter” LCP is a disservice to the individual and comes with consequences. CMS is likely to delay approval, costing time and money.

Many carriers choose to use one of the many national or local firms to write the LCP for Medicare set-asides. However, some have decided to bring the function in-house as part of the routine of concluding complex claims.

At MEMIC, we’ve ventured down this road and to date have incurred no lost economic opportunities. In fact, we’re saving significant dollars with this initiative.

We concluded there are many advantages to promoting the use of our existing professional resources to write these plans for CMS approval. In our view, internal staff has immediate access to the claim files and medical reports. This eliminates the need for printing, copying and mailing. Furthermore, we project that turnaround time, depending upon volume, can be reduced to less than a week.

Undoubtedly, the most striking advantage to internalizing the process is that of cost. Currently, the expense of a vendor to write a plan for submission to CMS is in the $1,500-to-$6,000 range, depending on complexity. We calculate that the same service performed in-house runs $500 to $1,500.

Certification lends credibility
For MEMIC, it seems to be a natural fit and relatively easy. The first step is to determine whether the talent is on board. Since we have a sizable contingent of medically trained individuals, the next step is to obtain the credentials. While CMS doesn’t require certification, it certainly lends credibility before the plaintiff counsel and CMS advocates.

Currently, there are two widely recognized certifications for life care planning. They are a certified life care planner (CLCP) and a certified nurse life care planner (CNLCP). The principal differences lie in the certification body along with the training requirements for each program. One doesn’t take precedence over the other within the current fabric of the bureaucratic weave.

The CLCP can be attained by anyone in the rehabilitation field. The medically trained are joined by vocational rehabilitation counselors, social workers and like professional personnel. This certification is usually gained via an online course through Kaplan College. It is a 12-month course costing $3,350. Courses are completed through the internet with certification conferred upon course completion and acceptance of a “mock plan.”

An alternative is offered by the American Association of Nurse Life Care Planners. This course and the certification examination are accredited by the American Nurses’ Association.

It’s a week-long intensive program offered twice a year in Salt Lake City in March and September. The course provides 60 CEU hours which makes the participant eligible to sit for the certification exam. This exam is held twice a year in regional locations and, after successful completion, one is granted the certification of CNLCP, which is good for five years. Cost for the course and exam is $2,855 to $3,500.

Writing life care plans may not be something other AASCIF members are interested in doing. Some might argue that carriers need not get involved in the development of a plan since it is an exercise and expense better taken on by employee counsel. Be that as it may, for those of us who find value in the product, it’s nice to know we can create it at home.

Authors John Marr and Wendy Coyne can be reached at (207) 791-3300 or jmarr@memic.com or wcoyne@memic.com

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