Medical Cost Projection vs. Life Care Plan: Which Does Your Case Need?
Dr. Andrew Tisser, DO MBA CPE CLCP & Gina Marra, RN LCSW LNC CLCP
When a serious injury case involves future medical expenses, attorneys are often faced with an important threshold question: does the case require a medical cost projection or a comprehensive life care plan? The two services overlap, but they are not interchangeable. The primary difference is scope.
A medical cost projection is generally appropriate when the future medical care is already reasonably identifiable in the medical record and the primary question is what that care is likely to cost. A life care plan goes further. It evaluates the broader future-care picture, develops a comprehensive model of the individual's anticipated needs, and then determines the associated costs. Understanding that distinction can help counsel select the appropriate level of analysis for the case.
What Is a Medical Cost Projection?
A medical cost projection is a focused analysis of anticipated future healthcare expenses. The process begins with the medical record. Future treatment recommendations are identified, the applicable medical services and procedures are defined, and current geographically appropriate cost data are used to estimate the associated expenses.
Depending on the case, projected costs may include physician and specialist follow-up, surgical procedures, hospital or facility services, diagnostic imaging, injections and other procedures, physical, occupational, or other therapies, medications, durable medical equipment, and medical supplies. Where appropriate, services are identified using CPT, HCPCS, DRG, or other relevant coding systems. Cost research should account for geography and the specific component of care being priced, including professional, facility, anesthesia, equipment, or other applicable charges.
The objective is not simply to attach a dollar amount to a diagnosis. The objective is to create a transparent and reproducible estimate of the future medical care that is supported by the available evidence.
When Is a Medical Cost Projection Appropriate?
A medical cost projection may be appropriate when future treatment recommendations are already reasonably well defined, when the treating providers have identified anticipated procedures or ongoing care, and when the primary issue is the cost of that care rather than determining the full range of future needs. It also fits cases involving a relatively focused future-treatment course, where counsel needs a defensible future-medical damages analysis without the broader scope of a comprehensive life care plan.
For example, if the medical record documents a recommended future surgery, postoperative rehabilitation, periodic imaging, specialist follow-up, and ongoing medications, a medical cost projection may be able to quantify those anticipated expenses without developing an entirely new care plan.
What Is a Life Care Plan?
A life care plan addresses a broader question: what will this individual reasonably need in the future as a result of the injury, and what will those needs cost? Rather than simply costing an existing set of treatment recommendations, the life care planning process evaluates the individual's medical condition, functional limitations, prognosis, and anticipated future needs.
Depending on the case, a comprehensive life care plan may address physician and specialist care, future procedures and hospitalization, therapy and rehabilitation, medications, diagnostic testing, durable medical equipment, orthotics and prosthetics, medical supplies, attendant or supportive care, home or environmental modifications, transportation-related needs, and other medically or functionally necessary services. The analysis may also incorporate information from treating providers and appropriate specialists when the future-care questions extend beyond the expertise of the core planning team. The result is a comprehensive future-care model rather than simply a list of projected medical costs.
Medical Cost Projection vs. Life Care Plan
Both begin with a medical record review and both rely on geographically relevant cost research. The difference is what happens before the costing. A medical cost projection answers what identified future care will cost, and it is best suited to cases where the future care is already defined; the development of broader future-care needs is limited, and functional and support needs are typically addressed only in a narrow way.
A life care plan answers what this person will need and what it will cost. It does not assume the future care is already defined. It develops the broader future-care model, evaluates functional and support needs where applicable, and is best suited to complex or catastrophic future-care needs. In short: the projection is focused and the plan is comprehensive.
When Does a Case Need a Life Care Plan Instead?
A life care plan may be more appropriate when the future-care picture itself is uncertain, complicated, or extends significantly beyond the treatment currently documented in the medical record. This is particularly relevant in cases involving spinal cord injury, traumatic brain injury, amputation, severe neurologic injury, birth injury, significant burns, complex orthopedic trauma, long-term functional impairment, a need for attendant care, major equipment or accessibility needs, or the involvement of multiple medical specialties.
In these cases, simply costing a handful of existing recommendations may significantly understate the actual future-care issues. The assignment may require someone to develop the future-care model before that model can reasonably be costed.
The Difference Is Scope, Not Simply Case Value
A medical cost projection should not be viewed as a smaller or less expensive version of a life care plan. They answer different questions. When future treatment is already reasonably established, a medical cost projection can provide a focused analysis of the associated costs without unnecessarily expanding the assignment. When the future medical and functional picture itself needs to be developed, a comprehensive life care plan is generally the more appropriate tool. Selecting the right scope at the beginning of the case can also make the resulting analysis easier to explain and defend later.
The Case Veritas Approach
At Case Veritas, both medical cost projections and life care plans begin with the same principle: the medical evidence should drive the numbers, not the other way around. Future-care recommendations are evaluated first. Appropriate medical coding and geographically relevant cost data are then used to determine the associated expenses. For more complex cases, appropriate specialists can be incorporated when the medical issues extend beyond the core planning team's expertise. The objective is not to produce the largest possible damages figure. It is to develop a clinically coherent, transparent, and defensible analysis of future medical needs and costs.
Not Sure Which Your Case Requires?
If the future treatment recommendations are already well established, a medical cost projection may be sufficient. If the future-care picture remains complex or incomplete, a life care plan may be more appropriate. Contact Case Veritas with the basic case information and existing future-treatment recommendations, and we can help determine the appropriate scope before the engagement begins.
This article is provided for general informational purposes and is not legal advice.
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