When is a Medical Cost Projection Recommended?

Medical Cost Projections are recommended to establish accurate reserves for the future medical costs of complex, large loss claims, often associated with catastrophic injuries. Catastrophic claims can extend over decades, racking up millions of dollars in medical costs. For this reason, setting an accurate reserve is absolutely critical to the financial well-being and security of the carrier and/or the employer.

Medical Cost Projections and the Complex Large Loss Claims

Oftentimes, large loss claims are highly complicated with multiple factors driving exposure and complex information needing to be weighed. The complex nature of large loss claims can stem from several elements:

• Multiple co-morbidities such as diabetes, multiple infections, respiratory ailments, heart disease.
• Injuries may include fractures that do not heal or develop infections, traumatic brain injuries, spinal cord injuries, amputations, and multiple surgeries.
• Treatment is ongoing resulting frequent reserve increases.
  • Reserves may become exhausted prematurely as a prior review did not include new or increasing exposures.
• Pain management treatment, including high medication utilization with escalating medication costs.
  • May also include the use of pain pumps and/or spinal cord stimulators.
• Ongoing frequent physician visits with multiple providers, possibly creating polypharmacy.
• It is often helpful to develop a Medical Cost Projection when settling a claim with an undocumented worker.
  • Cost Projections can be useful in detailing anticipated future care should the worker intend to permanently relocate outside of the United States.

The volatile nature of catastrophic claims makes accurately setting a reserve no small task. It requires the highly credentialed expertise and comprehensive analysis that a Medical Cost Projection program can provide. At ANS, our national network of highly credentialed nurse experts have extensive catastrophic injury experience and are able to apply jurisdictional specific knowledge to the cases they are strategically assigned.

ANS Approach to Medical Cost Projection

The ANS approach to Medical Cost Projections combines an evaluation of potential areas of exposure with potential areas of savings to provide a complete plan of action. Our findings are independently examined using expert medical and cost data sources. The resulting evidence-based recommendations achieve the best possible outcome from a cost and quality of care perspective. For more information on ANS Solutions’ industry leading approach to Medical Cost Projections, contact us today at www.ans-solutions.com.

This content was originally posted at www.ans-solutions.com.

The Perfect Storm: Rising Pharma Costs & Part D

As we all know, injured worker treatment regimens relying heavily on costly prescriptions is the unfortunate norm. On top of that, pharma costs are continually rising, surpassing general and medical cost inflation. It seems that Payers can’t catch a break. To add insult to injury, Medicare Part D came into existence as part of the Medicare Modernization Act, which further mandated the inclusion of prescription drug coverage in Medicare Set-Asides. Accounting for prescription drug coverage in the face of inflating pharma costs and excessive prescriptions is the perfect storm for excessive MSAs, resulting in fewer settled claims.

Mitigating MSA Part D Exposure

To reach settlement quickly and with optimal results for both Payer and Claimant, a comprehensive expert approach is necessary. At ANS we mitigate Medicare Set Aside Part D exposure with a unique three step approach.

PharmReview – Pharm Ds examine the worker's current treatment and recommends modifications, often finding similar or superior results that can be achieved using less expensive drugs or alternate therapies, producing improved results for both the worker and the carrier.

PharmIntervention - To address these recommended conversions, an ANS Nurse Expert meets with the injured worker's physician to develop a new pharmaceutical regimen based on the expert review and recommendations. Significant MSA savings are often achieved by formally discontinuing previously prescribed medications, allowing their removal from the MSA.

PharmCompliance - To ensure hard dollar savings and a positive therapeutic outcome, each case requires proactive management. An ANS Clinical Liaison Officer is assigned to every case and employs protocols to ensure the new regimen is adhered to by both the treating physician and claimant.

Experience shows that ANS Solution's comprehensive Pharmacotherapy Review Program can reduce pharma costs by as much as 25%. Settlements are optimized, and achieved faster with lower costs. ANS’ program often leads to the claimant obtaining an improved quality of life.

To learn more contact us at www.ans-solutions.com.

This content was originally posted at www.ans-solutions.com.

Advanced Strategies for Pharmaceutical Cost Management

With large loss claims, the road to managing the hefty costs associated with pharmaceutical therapies can be long and winding. As more drugs become available within drug classes, there is often a large cost disparity among medications. Further, patient access to more affordable and equally (if not more) effective medications is limited. Fortunately, there are advanced pharmaceutical cost management solutions available. One such solution, Pharmacotherapy Review, is ANS’s highly evolved approach to drug utilization review. The Pharmacotherapy Review Program utilizes a three-stage approach to provide economically balanced and appropriate treatment options for injured workers.

PharmReview – Stage 1

At ANS we are not just concerned with cost-effective treatment regimes. Overall our strategies strive to improve the quality of life for the injured worker. The PharmReview program applies evidence-based medical guidelines when strategically assessing each case to identify the best possible clinical and pharmaceutical treatment plan based on the injured worker’s medical condition. The final product is an expert recommendation on a course of action to improve the living conditions of the injured worker while reducing unnecessary costs for the carrier.

PharmIntervention – Stage 2

PharmIntervention involves applying expert clinical knowledge and experience in catastrophic injures to recommend, where appropriate, alternative treatments and therapies. The goal of this strategy is to improve quality of care and overall outcomes. Achieving this goal requires a thoughtful and collaborative partnership between treating physicians to employ a modified treatment plan based on the recommendations of highly credentialed and experienced nurse experts. When done correctly it will ensure that patients receive the highest quality of care balanced with the necessary cost controls.

PharmCompliance – Stage 3

Physician and patient compliance with the new prescription plan established during the PharmIntervention stage is crucial to a successful pharmaceutical cost management strategy. First, it will help determine whether the modified treatment plan is achieving the desired result. Second, it will ensure both the physician(s) and injured worker are actively engaged in the new treatment regime. Compliance by both parties will generate hard dollar cost-savings and positive therapeutic outcomes. In this stage, ANS Clinical Liaison officers will pro-actively manage a case to ensure compliance and maximize outcomes.

ANS Solutions

Effective use of advanced pharmaceutical cost management tools such as ANS PharmReview Program can minimize overall costs, improve patient access to more affordable medications and provide an improved quality of life. Our pharmaceutical cost containment strategies have achieved proven results time and time again. To find out more about our medical cost management services visit us at www.ans-solutions.com.

Content originally posted at www.ans-solutions.com.

The Human Side of Medical Cost Management

When we talk about the costly nature of large loss Workers’ Comp claims, it is sometimes hard to think beyond the financial impact.  Further to this point, when medical cost containment strategies are discussed they are often geared toward addressing the clinical and pharmaceutical treatment programs for injured workers from a financial perspective. What about the less tangible side of medical cost containment-the human costs which are equally as significant and damaging?

Addressing Human Costs in Medical Cost Containment

When we talk about the human cost of large loss claims, we are really talking about the effect a case has on the quality of life for an injured worker and their family. While all medical cost containment strategies focus on financial cost drivers, not all strategies address human costs. There are many drivers that can contribute to compromising an injured worker’s quality of life. These human cost drivers include, but are not limited to:

·         Pain treatment through highly addictive opioids, coupled with a lack of patient education on the risks and dangers of these drugs, subjects injured workers to a path of drug addiction which may hinder or prevent their recovery.

·         Lack of appropriate physician monitoring and/or patient compliance to a prescribed medical treatment regimen can contribute to a longer recovery period.

·         Lack of monitoring patient’s treatment program and progress results in missing the warning signs of drug abuse and addiction, missed opportunities to modify a treatment program based on patient’s recovery, lost opportunities to modify treatment based on the availability of alternative treatments and therapies that may be more effective, and have fewer side effects.

·         Lack of coordination between multiple treating physicians can attribute to greater increase for drug abuse or unnecessary or inappropriate pharmaceutical and medical treatments.

ANS Cost Containment Strategies

The ANS PharmacotherpyReview Program is the most advanced and results-oriented cost containment strategy in the industry. At the first of three stages, we assess the existing treatment program using evidence based reviews to assess medical necessity. We also identify duplicate therapies, excessive dosages and alternate medication regimens. Our experts then make actionable treatment modification recommendations that ensure optimal outcomes for the patient. This includes consolidating and coordinating drug therapies between multiple prescribers.  In the second stage, our nurse experts work with treating physicians to obtain commitment on a modified future course of treatment. For a positive therapeutic outcome, we move to stage three where an ANS Clinical Liaison Officer proactively manages each case to ensure physician and patient compliance with the revised course of treatment.

ANS Solutions

Our approach to cost containment was uniquely developed to simultaneously ensure a medically appropriate and cost effective treatment program and enhanced quality of life and care for the injured worker. For more information on our industry leading cost containment strategies visit us at www.ans-solutions.com. 

This content was originally published at www.ans-solutions.com.

 

The Medical Legal Nurse Consultant – A Jack of All Trades

Medical legal claims typically involve complicated, long-term medical issues and represent an enormous financial burden for Payers. In order to mitigate this financial exposure it is crucial for Payers to accurately assess the true value of alleged damages. But this is no small task and it often requires extensive investigation and expert interpretation. Let’s be honest, mitigating financial exposure can only effectively be done by a highly credentialed few, those with a hybrid skillset of healthcare expertise, specialized legal training, and first-hand experience in complex liability matters such as GL, toxic exposure, personal injury, and malpractice. 

With qualifications in both medical and legal fields the Legal Nurse Consultant is perfectly poised to aid insurance companies who want to optimize their results and settle large claims once and for all. By definition, a Legal Nurse Consultant is an individual with healthcare expertise who has taken additional specialized legal training so that they can consult as an expert on medical cases, but this is just the tip of the iceberg.

Medical Legal Nurse Consultant Litigation Support

In litigation support, the data and reporting generated by legal nurse consultants can provide an extraordinarily powerful legal instrument in the negotiation of a claim. At ANS, our strategy for mitigating and defending medical legal claims involves a host of strategic activities including:

• The critical analysis and review of initial complaints, supporting medical & legal documentation and pricing to allow for an accurate assessment of true damages.   
• Review of medical causation and exposure to effectively gauge merits of alleged injuries while identifying any missing medical information that may prove valuable to the claim.
• Generating an expert assessment and opinion based on a detail of record and all documented encounters with medical systems. 
• Uncovering causation, mitigating factors, unreasonable medical charges, inappropriate/red flag patterns of care, and unnecessary and unrelated care issues are exposed
• Providing a counter analysis in the event that a plaintiff future cost of care report is submitted.

Medical Class Action & the Medical Legal Nurse Consultant

Navigating a medical claim involved in a class action is difficult to say the least. Class actions are very large in scope requiring the dissection and digestion of thousands of pages of legal and medical documentation. Fortunately, medical class actions are another area of support fielded by ANS’s legal nurse consultants.  We have extensive experience in handling class action and large tort cases. If you have a medical legal claim involved in a medical class action case, our medical legal nurse consultants can assist by providing:

• Initial screening for merit and damages.
• Analysis of massive amounts of data quickly and accurately creating a snapshot of the case.
• Recommendation for appropriate next steps based on medical review.

At ANS, our team of nurse experts, are highly credentialed and wield an average of 25 years in specialized nursing experience. In addition, their scope of jurisdictional expertise yields unparalleled results. To find out more about ANS Solutions’ superior medical legal nurse consulting services visit us at http://www.ans-solutions.com.

This content was originally posted on http://www.ans-solutions.com.

The Medical Legal Nurse Consultant – A Jack of All Trades

Medical legal claims typically involve complicated, long-term medical issues and represent an enormous financial burden for Payers. In order to mitigate this financial exposure it is crucial for Payers to accurately assess the true value of alleged damages. But this is no small task and it often requires extensive investigation and expert interpretation. Let’s be honest, mitigating financial exposure can only effectively be done by a highly credentialed few, those with a hybrid skillset of healthcare expertise, specialized legal training, and first-hand experience in complex liability matters such as GL, toxic exposure, personal injury, and malpractice. 

With qualifications in both medical and legal fields the Legal Nurse Consultant is perfectly poised to aid insurance companies who want to optimize their results and settle large claims once and for all. By definition, a Legal Nurse Consultant is an individual with healthcare expertise who has taken additional specialized legal training so that they can consult as an expert on medical cases, but this is just the tip of the iceberg.

Medical Legal Nurse Consultant Litigation Support

In litigation support, the data and reporting generated by legal nurse consultants can provide an extraordinarily powerful legal instrument in the negotiation of a claim. At ANS, our strategy for mitigating and defending medical legal claims involves a host of strategic activities including:

·         The critical analysis and review of initial complaints, supporting medical & legal documentation and pricing to allow for an accurate assessment of true damages.   

·         Review of medical causation and exposure to effectively gauge merits of alleged injuries while identifying any missing medical information that may prove valuable to the claim.

·         Generating an expert assessment and opinion based on a detail of record and all documented encounters with medical systems. 

·         Uncovering causation, mitigating factors, unreasonable medical charges, inappropriate/red flag patterns of care, and unnecessary and unrelated care issues are exposed

·         Providing a counter analysis in the event that a plaintiff future cost of care report is submitted.

Medical Class Action & the Medical Legal Nurse Consultant

Navigating a medical claim involved in a class action is difficult to say the least. Class actions are very large in scope requiring the dissection and digestion of thousands of pages of legal and medical documentation. Fortunately, medical class actions are another area of support fielded by ANS’s legal nurse consultants.  We have extensive experience in handling class action and large tort cases. If you have a medical legal claim involved in a medical class action case, our medical legal nurse consultants can assist by providing:

• Initial screening for merit and damages.
• Analysis of massive amounts of data quickly and accurately creating a snapshot of the case.
• Recommendation for appropriate next steps based on medical review.

At ANS, our team of nurse experts, are highly credentialed and wield an average of 25 years in specialized nursing experience. In addition, their scope of jurisdictional expertise yields unparalleled results. To find out more about ANS Solutions’ superior medical legal nurse consulting services visit us at http://www.ans-solutions.com.

This content was originally posted on http://www.ans-solutions.com.

The Financial Repercussions of MSAs on Large Loss Claims

Medicare recommends an allocation of funds in a Workers’ Compensation settlement that is set aside to ensure that the injured party’s qualified medical expenses are funded, also known as Medicare Set Aside. These funds must be used to pay for treatment related to the Workers’ Compensation injury, that would otherwise be paid for by Medicare. The financial repercussions of MSAs on settlements can be significant.

Part D Exposure

As part of the Medicare Modernization act of 2003, Medicare indoctrinated what is known as Part D prescription drug coverage beginning in 2006. In other words, an allocation must be made for future prescription drug treatment in a Medicare Set-Aside. Rising pharmacy costs, including medications an injured worker may have been prescribed once in the previous 2 years, along with treatment, has created an environment in which Payers are subject to unreasonably high claim settlements.  The “Prescription Affliction” suffered by Payers is lovingly referred to as Part D exposure and it leads to claims staying open longer or not settling at all. As a result, these claims rack up millions of dollars in cost for Workers’ Compensation Payers.

Reducing Medicare Set Aside and Part D Exposure

A proactive approach is necessary before settlement and preferably early in the process for optimal results. At ANS, we mitigate Medicare Part D exposure with a three pronged approach:

• PharmReview – during this stage, the injured worker’s existing pharmaceutical regimen is assessed and modification recommendations are determined.
• PharmIntervention – a face-to-face discussion with the treating physician to achieve consensus on a modified medication regimen and commitment on a future course of treatment.
• PharmCompliance- an ANS Clinical Liaison Officer ensures compliance with the new prescription treatment plan. This provides a proactive management of the case to optimize hard cost savings.

Only highly credentialed legal nurse experts who are experienced in the treatment of catastrophic injuries, such as those employed by ANS, can provide actionable recommendations based on the individual patient and engage effectively with treating physicians. This technique yields a clear medical action plan that drives down costs while simultaneously improving the quality of care for the injured worker, allowing for reasonable settlement of the claim.

ANS’s pharmaceutical cost containment technique has reduced pharma costs by up to 25%. To find out more about reducing MSA and Part D exposure, contact us today.

This post was originally published at http://ans-solutions.com/.