Kim Wages BSN RN BBA CRRN CNLCP® LCP-C MCP-C MSA-C’s Post

FUN FRIDAY Referral – Role – Consultant BY Shelene Giles, CEO FIG Education The Consultant Life Care Planner may be asked to develop a fragmented version of the Life Care Plan, often referred to as a Medical Cost Projection. This Medical Cost Projection outlines the estimated future medical care needs and associated costs. Typically, the purpose is to provide a quick analysis of the injury and best estimation of the costs for the future medical care of the injured individual. Some important details must be discussed with the retaining party if they request a Medical Cost Projection in an effort to protect any future expert witness from a Daubert challenge. This will be discussed in greater detail throughout this lessons and upcoming lessons. The purpose of this type of retention is somewhat different in that the referral source may want to understand the injury, the treatment, and any potential confounding problems with the case before he or she decides to take on the case. The insurance adjuster may ask for the Medical Cost Projection to set reserves, adjust reserves in a special needs trust, or may have an upcoming mediation or settlement conference scheduled. If there is a mediation scheduled, the insurance adjuster, plaintiff attorney, or defense attorney may request a summary of the medical records to outline the damages and an estimated cost of future medical care that can be used to settle the case. In this case, a Life Care Planner expert witness may not have been designated by either the plaintiff or the defense side. The retaining attorney hires a Life Care Planner as a consultant to have a better understanding of the cost of the medical needs that can be included in the mediation settlement negotiations. #nurses #ot #pt #md #casemanagement #legalnurseconsultant

FUN FRIDAY Referral – Role – Consultant BY Shelene Giles, CEO FIG Education The Consultant Life Care Planner may be asked to develop a fragmented version of the Life Care Plan, often referred to as a Medical Cost Projection. This Medical Cost Projection outlines the estimated future medical care needs and associated costs. Typically, the purpose is to provide a quick analysis of the injury and best estimation of the costs for the future medical care of the injured individual. Some important details must be discussed with the retaining party if they request a Medical Cost Projection in an effort to protect any future expert witness from a Daubert challenge. This will be discussed in greater detail throughout this lessons and upcoming lessons. The purpose of this type of retention is somewhat different in that the referral source may want to understand the injury, the treatment, and any potential confounding problems with the case before he or she decides to take on the case. The insurance adjuster may ask for the Medical Cost Projection to set reserves, adjust reserves in a special needs trust, or may have an upcoming mediation or settlement conference scheduled. If there is a mediation scheduled, the insurance adjuster, plaintiff attorney, or defense attorney may request a summary of the medical records to outline the damages and an estimated cost of future medical care that can be used to settle the case. In this case, a Life Care Planner expert witness may not have been designated by either the plaintiff or the defense side. The retaining attorney hires a Life Care Planner as a consultant to have a better understanding of the cost of the medical needs that can be included in the mediation settlement negotiations. #nurses #ot #pt #md #casemanagement #legalnurseconsultant

Perspective shapes position. As a nurse, typically you are in the position of helping someone who is unwell/hurt/broken. With this perspective in mind you would think that every nurse would jump at the opportunity to help with plaintiffs sided matters. However, I know some nurses who were called to testify on a medical malpractice case -- that they were tangentially involved in & the experience left them a bad impression of plaintiffs attorneys. They never wanted to be anywhere near a lawsuit afterwards. I see people who are in chronic pain every day, every day they hurt. This perspective makes me believe in the work that plaintiffs attorneys do. One crash, one incident is all that separates us from the same fate. I am sure, on occasion insurance companies do the right thing at the right time and people get taken care of. But I also battle with insurance companies on a daily basis to get medications approved for these people. Every profession has its bad actors and its ugly ones too. There isn't a need to convince myself that I'm doing the right thing when it involves helping people with real injuries. But its just my perspective. -- Hey I'm Josh, I'm a registered nurse that works in chronic pain and helps plaintiffs personal injury attorneys with reviewing medical records, medical cost projections and life care plans. [email protected]

NOT MEDICAL OR LEGAL ADVICE just stories from experience "With great power comes great responsibility" -Uncle Ben: Amazing Fantasy #15 1962 Oh, you want to refer for imaging in your PT clinic. Cool, but what do you do when insurance denies your referral? How will you handle the call? What are Peer-to-Peer Calls? PART 1 Peer-to-peer calls are scheduled phone conversations between the treating provider and a medical director from the insurance company. These calls typically occur after an initial denial of a prior authorization request for a medical service, such as imaging¹². The goal is to discuss the medical necessity of the requested service and potentially overturn the denial. Why Do They Happen? These calls happen because insurance companies use prior authorization as a cost-control measure. When a request is denied, a peer-to-peer call allows the treating provider to present additional clinical information and rationale directly to the insurance company's medical director². What Do These Calls Typically Mean? During a peer-to-peer call, the treating provider explains why the requested service is medically necessary based on the patient's clinical condition and relevant guidelines. The insurance company's medical director reviews this information to determine if the initial denial should be overturned²⁵. Protocols for Peer-to-Peer Calls Insurance companies often have specific protocols for these calls, which "may" include: - Scheduling: Calls are usually scheduled within a specific timeframe (e.g., 24-72 hours) after the denial². - Duration: Calls typically last 5-10 minutes². - Documentation: Providers should have all relevant clinical documentation ready to present². - Expertise: The insurance company's medical director "should" have expertise in the relevant clinical area¹.🤣 Ok, I hit my post character limit 🤣🤣🤣 look out for Part II: Managing Peer-to-Peer Calls Effectively. 👍 if this was helpful. -Ry #medical #education #imaging ¹: [American Medical Association](https://lnkd.in/gNZRZ6xm) ²: [symplr](https://lnkd.in/gfUB_3QS) ³: [Sleep Review](https://lnkd.in/gtbXDFpw) ⁵: [The Healing NET Foundation](https://lnkd.in/g4xpXzCE)

I’m excited to talk to you about the physician credentialing process and its career opportunities. -How many of you are currently working in the medical field? -Have you ever wondered how doctors process claims and get contracts from insurance companies? -Today, we’ll explore the business side of the medical field, specifically the credentialing department. -Credentialing Process Credentialing involves collecting, organizing, and processing physicians’ information to send to insurance companies. There are three important aspects to understand: salary range, qualifications, and the credentialing process itself. 1. Salary Range The salary varies by state and experience, typically ranging from $28,000 to $50,000 annually (based on payscale.com). 2. Qualifications You don’t need any qualifications, However I do provide premium trainings. 3. Credentialing Process: Step 1: Letter of Intent The doctor expresses interest in joining an insurance network. The credentialing specialist collects and processes this letter. Step 2: Application and Checklist The insurance company sends an application and checklist to the doctor. The doctor completes the application, attaching documents like a CV, medical degree, certificates, driver's license, and social security card. Step 3: Verification and Submission The credentialing specialist verifies the documents and sends the package to the insurance company. Step 4: Insurance Company Review The insurance company reviews the application in a general meeting, usually held monthly. If approved, the provider relations department sends a contract to the doctor. Step 5: Contract and Welcome Letter The doctor reviews and signs the contract if they agree to the terms. A final Welcome Letter with an effective date is issued, allowing the provider to submit claims. There are many opportunities in the medical field, and credentialing is a crucial part of it. Do you have any questions or any thing that i may have missed let me know? #credentialing #medicalbilling #doctoroffice #privatepractice #rcm

Insight: Understanding Government Concerns on Medical Malpractice Cover The recent government consultation document has raised several critical concerns about the stability of current indemnity cover for professionals outside state-backed schemes. Key issues highlighted include: - Discretionary Indemnity: Unlike commercial insurance, discretionary indemnity providers have no contractual obligation to cover claims, posing significant risks to professionals. - Financial Reserves: These providers aren't legally required to maintain sufficient reserves to cover claims, potentially leaving patients without appropriate compensation. - Transparency: There's a lack of mandatory financial disclosure, meaning professionals might be unaware of their indemnity provider's financial health. - Regulation: Discretionary indemnity providers aren't subject to FCA or PRA regulation, increasing the risk of unfair treatment. Further concerns were echoed in the Paterson inquiry report, which spotlighted the struggle of private patients to access compensation compared to NHS patients under the CNST. The report urged urgent reform of indemnity regulation to prevent patient disadvantage. At THEMIS, we recognize the pressing need for robust, transparent, and regulated indemnity solutions to protect both professionals and patients. #IndemnityCover #HealthcareReform #PatientSafety #ProfessionalLiability #THEMISBroker https://lnkd.in/eYat4_XD

The Mystery of Doctor Credentialing: Doctor credentialing is the process by which a third party evaluates the history, qualifications, experience, and ongoing education of a practicing physician or healthcare professional. Credentialing allows insurance companies and patients to ascertain the quality of care they can expect to receive from the doctor in question. It also protects patients by verifying any malpractice claims or disciplinary action that has been taken against the doctor. First, the credentialing agency investigates the physician’s education and training. It is essential to ensure the doctor’s training is complete and that they are certified to practice medicine in each state where they are licensed. Next, the doctor is evaluated based on their personal and professional background and history. All information is verified through national agencies like the American Board of Medical Specialists. The doctor’s residency, licenses, and certifications are then researched and investigated by the credentialing company. Doctor credentialing is used to inspect all aspects of a physician’s life, from their personal history to their malpractice insurance. As a practicing physician, it’s important to make sure that all areas of your professional life are accessible and accounted for to ensure an accurate vetting process. The process of credentialing is an on-going, career-long endeavor conducted to ensure transparency and integrity in the medical industry, and to give patients peace of mind about choosing you as their healthcare provider. To learn more about doctor credentialing, insurance, coding, outsourcing, and everything you need to establish a successful healthcare practice, follow all of Sherlock Doc’s adventures on the DoctorsBusinessNetwork.com or Doctors Business Channel on YouTube!. http://dlvr.it/T46Kd2 #MedicalNews #DoctorsBusinessNetwork #HealthcareNews

Insurance companies can be really tricky when it comes to giving back the money you're owed. There are tons of rules and hoops to jump through, which can make it tough for many businesses. If you're having a hard time getting your money back, it's usually not because you're not doing a good job. It's more likely because of how the systems are set up. The key is to learn how to navigate these systems. Understand how insurance payments work and the process for getting reimbursed. Once you do, you'll be able to make sure you're getting all the money you deserve. Don't worry, you've got this! Credentialing Batch starting 13th of April. #medicalbilling #medicalcoding #credentialing #rcm #physician #nursepractinioners

TIDBIT TUESDAY! Referral, Review and Summary Shelene Giles, CEO FIG Education Patient care plans have been used as a tool to help patients, families, nurses, case managers, and rehabilitation professionals for decades and decades. The concept of a Life Care Plan was a spin-off of patient care plans. Insurance adjusters and attorneys realized the benefit and value of a Life Care Plan in the claims and litigation setting. Primarily in the workers’ compensation field, insurance adjusters rely on this concept for setting and adjusting reserves as well as settlement planning. Insurance adjusters received notice of a workers’ compensation claim within hours after injury. Insurance adjusters were tasked with asking and answering two questions – what is the likely outcome and what is this going to cost. Insurance adjusters rely on Case Managers and Life Care Planners to answer these questions. This way, insurance adjusters can accurately predict the expenses on this claim, then readjust during the interim of the case, and then plan for mediating the case. Plaintiff attorneys ask the same questions for similar and different reasons. Plaintiff attorneys will take a look at the case to determine their return on investment before taking the case. Plaintiff attorneys want to know if this case is worth taking or should they refer to a colleague. Plaintiff attorneys may ask these questions again during the interim of the case when developing a strategy and planning for settlement. Plaintiff attorneys may also ask for a final answer when gearing up for mediation or trial. #nurses #ot #pt #doctor #casemanagement #legalnurseconsultant

Case Note: Indian Medical Association v. V.P. Shantha & Ors, (1995) 6 SCC 651 Issue The primary issue in Indian Medical Association v. V.P. Shantha & Ors was whether medical services fall under the purview of the Consumer Protection Act, 1986, thus allowing patients to seek redressal for medical negligence through consumer courts. Rule The Consumer Protection Act, 1986, defines "service" as any service which is made available to potential users. It includes services of various kinds, such as those provided by professionals, except the rendering of any service free of charge or under a contract of personal service. Application The Supreme Court analyzed the definitions provided in the Consumer Protection Act and interpreted the term "service" to include medical services, provided for consideration. The Court clarified that the following medical services are covered under the Act: Medical Services for a Fee: Services provided by medical professionals for a fee are included under the Act. Medical Services at Hospitals: Services provided at hospitals where patients are charged are included. Medical Services Under Insurance: Services provided under insurance coverage or under an agreement are included. The Court also distinguished between a contract of personal service (which is excluded) and a contract for personal services (which is included), ruling that the relationship between a doctor and patient is that of a contract for personal services. Conclusion The Supreme Court concluded that medical services provided for a fee fall within the ambit of the Consumer Protection Act, 1986. Consequently, patients who suffer from medical negligence can seek redressal through consumer courts, enhancing the accountability of healthcare providers and providing an accessible remedy for aggrieved patients. Anmol Jain Ansari Solicitor Firm