Future Medical Cost Projections Module 2 Common Factors in Cost Projecting
Common Factors in Cost Projecting Overview Discusses common factors in calculating future medical cost projections Objectives Be able to explain difference between rated and chronological age life expectancy Be able to discuss various types of fee schedules Be able to define various coding acronyms Be able to list standard treatment categories Be able to provide overview of case management protocol Copyright InSitu Academy
Copyright InSitu Academy Factors Life expectancy Fee schedules Coding Copyright InSitu Academy
Copyright InSitu Academy Life Expectancy Defines remaining years in life Chronological age: based on date of birth Rated age: based on medical condition and co-morbidities, calculated and documented by insurance actuary State statutes: most states have a code of law addressing life expectancy CDC mortality tables: tallied in male, female, total population, race, updated about every 1-2 years Copyright InSitu Academy
Copyright InSitu Academy Fee Schedules Worker’s Compensation Usual and customary Medicare Medicaid Billed rate Paid rate Collateral source rule Medication Copyright InSitu Academy
Worker’s Compensation Each state has its own fee schedule Some states have regional fee schedules Some are based on a modifier of the Medicare fee schedule Not always updated annually Book or on-line format, not always both WC commissions offer very little guidance or support Used in MSA cost projections Copyright InSitu Academy
Copyright InSitu Academy Usual and Customary Used in personal injury cases Worker’s compensation attorneys sometimes want both charts: state fee schedule and usual/customary Physician’s Fee and Coding: common resource/reference High, low, modifiers Updated annually Copyright InSitu Academy
Copyright InSitu Academy Medicare Cases involving Medicare beneficiaries Used in post-settlement allocations Federal and regional guidelines Many exclusions for coverage Copyright InSitu Academy
Copyright InSitu Academy Medicaid Used for Medicaid recipients State specific guidelines Rarely encountered in our work Copyright InSitu Academy
Copyright InSitu Academy Billed rate All providers and facilities have a billed rate Also called published rate, full retail pricing Contracts based on reduction of billed rate Copyright InSitu Academy
Copyright InSitu Academy Paid rate Amount actually paid Differs from billed rate Cash rate for uninsured Contracted rate Confidential Non-transparent Copyright InSitu Academy
Copyright InSitu Academy Medication Many ways to cost out drugs Average wholesale pricing Uses Redbook as reference Generic pricing Used in our calculations unless contraindicated Brand name pricing Discount sources pricing Goodrx.com/CVS often used in cost projections and life care plans Compounded drugs No reliable reference Costs vary tremendously Copyright InSitu Academy
Copyright InSitu Academy Coding CPT codes: current procedural terminology: a coding system for medical procedures that allows for comparability in pricing, billing, and utilization review DRG codes: diagnosis-related group is a system to classify hospital cases ICD-10: The international Classification of Diseases, Tenth Edition, is a system of diagnosis codes and other codes that U.S. healthcare providers are now using Lots of books resources on coding, certification as a Coder available Copyright InSitu Academy
Copyright InSitu Academy Standard of Care Future medical cost projections include these categories Diagnostics Laboratory Physician visits Therapy Equipment Medications Injections Surgery Copyright InSitu Academy
Case Management Protocol Replacement scheduling Supplies and durable medical equipment Needs assessment: evaluations Copyright InSitu Academy
Copyright InSitu Academy Methodology Consistent approach Medical records review Client interview Billing records Other sources, not commonly available Depositions Physician conferences Pay-out history School records Copyright InSitu Academy
Copyright InSitu Academy Homework Download latest version of CDC (National Vital Statistics) life expectancy or mortality tables Research life expectancy chart for your state, plus one adjacent state, print and retain in records Calculate your life expectancy using all 3 charts Research state worker’s compensation fee schedule and if online version available, find CPT code 99213 (typically under E/M services) and determine cost Using online research (google), find CPT code for x-ray shoulder Copyright InSitu Academy
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