Life Care Planning and the Medical Fees Directory

It is important for life care planners to obtain appropriate cost information for the recommended treatment in a life care plan while adhering to life care planning tenets and standards. The most common method is to conduct a survey of the recommended treatment and ask for the “billed price” or the cash pay price without discounts. A range of sources is then included in the life care plan. Our policy at Stokes & Associates is to present the results of cost research to ensure that the treatment or service is not being under- or over-funded.

Many life care planners have begun using the Medical Fees Directory published by the Practice Management Information Corporation (PMIC) to obtain the cost information in their life care plans. The purpose of the PMIC is for physicians and providers to compare how their fees rank on a national basis. The text also reports the information can be utilized for negotiation with payers and other purposes. The PCIM did not intend this data to be used in pricing life care plans.

Furthermore, the PMIC provides costs at the 50th, 75th, and 90th percentiles, which are based on national averages and are generally reflective of payor allowables. The costs in a life care plan should be reflective of actual costs within the injured persons’ geographic area, not national averages. The use of the 50th, 75th, and 90th percentiles by the PMIC omits the top 10% and the bottom 50% of cost information A limitation of the resource is that by leaving out the bottom 50% and top 10%, the costs range may not include the treating physician’s cost, or the Usual and Customary Rate (UCR) costs in the patient’s geographic area.

The PMIC provides “GAF – Geographic Adjustment Factor,” which can be used to adjust the UCR by geographic area. For some areas, such as Mississippi, the text provides only one GAF multiplier for the entire state. It is unclear how specific this calculation can be to an individual’s geographic area given that the PMIC only provides one GAF in the entire state. While it is uncertain how reliable the GAFs are if a life care planner utilizes the PMIC, the GAF should be calculated because the costs across geographic regions can vary greatly.

The PMIC cost information is provided per CPT code. Unless the provider gives a specific CPT code(s) of services or the life care planner is extremely well-versed in how CPT codes are utilized, errors can easily occur. This is especially true if the life care planner is researching the cost of surgery, which could have multiple CPT codes, which can also vary by provider. The use of CPT codes could also leave the life care planner vulnerable to being accused of exceeding their scope of practice. For example, a physical therapy evaluation could be one of three CPT codes, each representing a differing level of complexity. Within the description, the level of complexity is determined in part by using “standardized patient assessment instrument and/or measurable assessment of functional outcome.” In choosing one CPT code over another, it could be argued that the life care planner is making a determination that should be reserved for a physical therapist.

At Stokes & Associates, we take great care to ensure that we are using best practices. For that reason, we advocate against relying entirely on published fee schedules for life care planning, such as the PMIC. Using the PMIC, in our opinion, does not give a comprehensive cost analysis and distorts the information presented to the trier of fact, rending the information invalid and unreliable.

To find out more about our methods or to discuss a potential case assignment, we offer complimentary consultations concerning "hypothetical matters."

To strategize with one of our vocational experts or life care plan experts at Stokes & Associates please call David Barrett at 504-454-5009, visit our website, www.stokes-associates.com or email dbarrett@stokes-associates.com.

Larry S. Stokes, Ph.D.

Aaron Wolfson, Ph.D.

Lacy Sapp, Ph.D.

Todd Capielano, M.Ed., LRC, CRC, LPC, CLC

David Barrett