Josh was involved in a slip and fall accident in which he sustained injuries to his cervical and lumbar spine. Prior to the accident, he was employed as a warehouse supervisor and worked long hours on a loading dock. He enjoyed riding a motorcycle, jet skiing, hiking, and traveling. Things went poorly for Josh following the accident. As he was no longer able to perform the necessary job duties of sitting or standing for an extended period of time, Josh was terminated from his job. He experiences chronic pain, has trouble performing necessary tasks around the house, can’t reach over his head, and requires a cane to walk.
Josh does not have health care insurance and has not been able to afford adequate medical care. Josh has outstanding bills for pain medication and doctors’ visits he could not afford to pay out of pocket. Cervical spine and lumbar spine surgery have been recommended; both expensive surgeries Josh would have to pay for out of pocket.
- Josh’s Lifetime Cost Projection began with a thorough file review of the medical records. From these records we obtained a complete picture of Josh’s diagnoses: internal derangement of the left shoulder, cervical disc syndrome with bilateral and upper extremity radicular symptoms, lumbar and thoracic disc herniation, post concussive syndrome, headaches and sleep disorder.
- With a complete understanding of Josh’s diagnosis, we interviewed him to obtain background information about his accident, medical history, treatment to date, and discuss his status. During the interview we reviewed the medications noted from the file review and had Josh confirm which were still being used. In addition, we discussed the details of how Josh’s accident has impacted his life.
- Additional costs and details considered in the cost projection included: cost of procedures, medications, which follow up treatments may be needed throughout Josh’s lifetime, equipment required following recovery from recommended surgery, assistance needed, and all associated costs.
The final Lifetime Cost Projection was completed by using Josh’s anticipated life expectancy – derived from the Social Security Actuarial Life Table – and calculating the total dollar amount Josh would need for lifetime treatment of his injuries. With that number in hand, we prepared our written Lifetime Cost Projection for submission to Josh’s attorney.
After submission of the Lifetime Cost Projection, we were again contacted by Josh’s attorney. Josh received one of the recommended surgeries but the bill was significantly higher than our projection. The attorney was concerned about the cost and requested we perform a Peer Review to obtain usual and customary costs for the procedure. Josh’s attorney planned to use our Peer Review findings to resolve outstanding physician/hospital bill. After researching various facilities and using the same CPT/Diagnostic code, we determined that Josh’s doctor was charging 50% higher than his peers performing the same procedure.
Josh’s attorney was successful in obtaining a substantial reduction of the bill so the bill could be covered by monies recovered in his settlement. Funds for future care remained from the settlement so Josh is able to cover the cost of his future medical needs.