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Animal Assisted Therapy Or Her Therapist was a Horse

Photo credit to The Columbus Dispatch / Eamon Queeney

Photo credit to The Columbus Dispatch / Eamon Queeney

As a retired long-term-care benefit analyst, the most heart-wrenching conversations I had were with families of cognitively-impaired individuals. Cognitive impairment can be diagnosed for a variety of reasons, but we are most familiar with Alzheimer’s/Dementia. This is also on my mind because I turned 65 last year and every time I lose a word, I wonder whether my mind is next.

Dementia therapy most often consists of crafts, exercise, and other activities seen as dementia management tools. But there are other methods that might be even more helpful.

Animal Assisted Therapy (ATT)

This story is about something else – alternative methods of helping people with Dementia, even if they don’t remember it later. At some point, the Alzheimer’s/Dementia experience can increase agitation and aggression. Patients become less physically active, withdrawn, and they eat very little. Keeping them always surrounded by others in the same condition does not help.

AAT has been conducted and studied to assist children and troubled teens, more commonly using dogs and cats. But does it also help adults?

Horse Therapy

Ohio State University, Field of Dreams Equine Educational Resource, and an adult day care participated in a small study with the results published recently in Anthrozoos. “We wanted to test whether people with dementia could have positive interactions with horses, and we found that they can—absolutely,” Dabelko-Schoeny said. “The experience immediately lifted their mood, and we saw a connection to fewer incidents of negative behavior.”

The results of this study suggest that AAT can also help adults. Clients of the adult day care visited a farm once a week. They walked the horses, groomed them, and fed them. As a bonus, they pushed their normal physical activity levels to interact with the horses. One family commented to researchers that her mother “would never remember what she did at the center during the day, but she always remembered what she did at the farm.”

Benefits of ATT

According to the National Institutes of Health’s website, ATT reduces behavioral and psychological symptoms of dementia (BPSD) for residents in long-term-care facilities. The presence of a small dog can reduce aggression and agitation and can also promote better social behavior. A small sampling of facilities indicates that residents eat more and gain weight if aquariums are placed in the dining rooms of dementia care units.

Alz.org blogger Sherri Snelling says, “The notion of pet therapy all began in the 1860s although most of the studies were conducted in the 1980s. While the medical community is still waiting for scientific data that shows pet therapy can have long-term or behavioral change benefits, even famous nurse Florence Nightingale recognized that animals provided a level of social support in the institutional care of the mentally ill over 150 years ago. In an effort to prove the therapeutic benefits of pet therapy, The National Institutes of Health has funded grants to study scientific evidence-based research in therapeutic effects on children.”

Why Isn’t ATT Common in Elder Care?

ATT requires a lot of planning, training, and work to make it safe. Additionally, science does not consider it to be scientific at this time. There aren’t enough controlled studies, and there isn’t enough information regarding a subject’s prior history with animals. What if they were bitten by a dog when young, for example? How can results of ATT be directly measured?

Just watch this video put together by Lakeview Ranch to see their experience with ATT. They believe that measurable results in Range of Motion therapy, the increased emotional and mental wellbeing of the residents, and better socialization skills all prove the value of animal assisted therapy.

What are we waiting for? Science? Aren’t those engaged faces enough?

“Animals are such agreeable friends, they ask no questions – they pass no criticisms.” George Eliot

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Part 4: My Long-Term-Care Claim is Approved. Now What?

canstockphoto15621077You might think that once your long-term-care claim (LTC) has been approved, you have no further obligation and that the insurance company will just keep paying until policy benefits run out. Not necessarily so.

Deductible period/elimination period (EP/DP). For LTC policies that have an EP/DP, this is the amount of time that must pass before the policy starts paying. It could be anywhere from zero to 100+ days and is usually based on dates of service received, not the amount of time that has passed. Often it must be satisfied within a specific period of time. For example, if you have a 20-day EP/DP that must be satisfied within 90 days, it will never be satisfied and the policy won’t pay if you only receive services once a week.

Some people stay on claim due to serious chronic conditions (such as Parkinson’s or severe Alzheimer’s/Dementia). However, there are illnesses or injuries where a reasonable expectation of recovery is present. For example, an insured could recover from a broken hip, a stroke, or a heart attack.

If you are no longer receiving assistance with activities of daily living (ADLs), and only need assistance with housekeeping, meal prep, or yard work, call the insurance company to avoid potential overpayments that must be reimbursed.

Your insurance company will also periodically review a claim to determine whether the insured remains benefit eligible. This is not because they are trying to get out of paying a righteous claim. It is because people do recover.

There are times when an assigned benefit analyst (BA) and a claimant don’t get along. This is not because the BA is incompetent or the claimant is impossible to deal with. Just politely request that a different BA be assigned.

If your policy requires bills as proof of loss, continue to send them in. Again, the contract is between you and the insurance company. They are not obligated to chase after bills every month, although some will, strictly as a courtesy. Even if arrangements have been made with a home healthcare agency, they do not always submit bills timely.

A claim could be underpaid or overpaid. Underpayments are self-explanatory. If it occurs, contact the insurance company and let them know. It will be fixed.

An underpayment or overpayment can also happen if the policy pays a different daily benefit for assisted living or nursing home stays. Always notify the insurance company if the insured changes location, even temporarily to a hospital. Particularly during the EP/DP.

If an overpayment occurs, an insurance company will require repayment. Two other likely causes for overpayments are:

  • Benefits are paid when an insured is no longer eligible;
  • The policy has a Medicare non-duplication clause. As above, always notify the insurance company if the insured changes location.

The insurance company also has clear responsibilities. But you can avoid problems, and fix them quickly once they occur if you pay attention and keep the lines of communication open with your Benefit Analyst.

The intent of these articles is to serve as a guide through the long term care claim process.

See Part 1

See Part 2

See Part 3

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Part 3: How NOT to Work with a Long Term Care Benefit Analyst

canstockphoto11493017I would bet that many claim professionals will applaud after they read the following, if only in secret. Insurance companies mostly are wise about customer service, but I have heard each of the following statements too many times from insureds, family, and agents. As I am no longer employed in the insurance business, I can now say what I think.

Turning down claims did not make me happy, but I took pride in doing the best job I could for both my insureds and my employer. While very sympathetic to the circumstances involved when people become ill, I have experienced extreme rudeness, been cursed at, called terrible names, and hung up on in conjunction with the following statements. Of course, anybody who deals with the public has experienced all of that at one time or another. My responses are what I wish I could have said, but didn’t, at least not so bluntly. Please do not say these things during the course of your claim.

I have been paying on this policy for X number of years and now it’s time for you to pay.
Yes, you may have paid for the policy for many years without reaping any direct benefit. That’s what insurance means. It’s no different than your auto or homeowner insurance. It just costs more because LTC claims cost more. It does differ in that you chose to purchase LTC insurance and were not forced to do so as with auto and homeowner. The good news is that you haven’t been sick enough to claim until now. Lucky people will never be so sick or injured that a claim is necessary.

You will be happy you bought the policy if you have to claim for an extended period of time. I also heard many people say how grateful they were that the policy was in place to help them or their parents. We all know how horribly expensive care can be. An insured on claim permanently could recoup all their premiums paid and much more.

My mother/father would never have bought a policy that: Had such a long waiting period; had such a low daily benefit; fill in the blank.

How could you say that? You weren’t there and too much of the time, you didn’t even know your parent had an LTC policy. The benefits your parents ended up with are usually the result of what they could afford at the time, or how much they were willing to pay. It’s about cost.

You insurance companies just want to cheat me/my parent so you won’t have to pay our claim.
There are so many ways this is a wrong statement. Insurance companies are officially regulated and subject to audits by 50 different state governments. They are also under federal scrutiny particularly where Medicare is involved and tax qualified versus non-tax qualified policies. Unofficially, they are watched by news organizations, lawmakers, and citizens.

Everybody likes to pick on insurance companies, and sometimes there is good reason. But they are not in the business of denying claims. They are in business of collecting enough premiums to cover claim expenses and, hopefully, make some profit. That being said, mistakes do happen and they should be addressed.

You are purposely delaying making a decision on my claim.

Or, my favorite, you’ve had my paperwork for several hours now, where is my decision. I’m sorry to say this, but you are not the only one submitting a claim. An insurance company wants you to feel like you are. They think that’s good customer service. When a BA is on the telephone for half an hour, or more, listening to you complain about insurance companies, and whatever else is on your mind, that’s half an hour of an eight-hour day, or more, when they can’t work on anybody’s claim. When you must call, please clearly state what you need. The BA should respond in kind.

It is not to anybody’s benefit to delay a claim decision. State insurance commissioners and auditors don’t like it and BAs don’t want to hear from disgruntled people all of the time. It makes them less effective in their work and BAs are inclined to want to help people.

All that being said, I have to confess that helping people through a difficult time in their lives was the most rewarding part of my job.

I’m going to call my lawyer or write the State Insurance Commissioner.
These words are usually said when somebody doesn’t like a claim decision or they think it’s taking too long. They do not strike fear in a BA’s heart, change a decision, or magically produce information that may be missing. If you really do feel that you have been wronged, just do what you think is necessary and don’t threaten people. It will never produce the desired results.

I cannot stress the word communicate enough. Problems often occur because of a misunderstanding on the part of the claimant, the BA, or the caregiver. Please have a civil conversation to try to find a resolution before you do or say anything unpleasant.

Remember that just because you don’t like a decision doesn’t mean that it is wrong. A policy is specific about how benefits can be accessed. Please understand that the purpose of this series is to assist you through the long term care claim process.

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Part 2: What if Your Long-Term-Care Claim is Denied?

Your Long-Term-Care Claim has been Denied

canstockphoto22814025If you receive a long-term-care (LTC) claim decline letter, please read it carefully. The insurance company should provide a written explanation explaining why the claim doesn’t meet the policy eligibility requirements. Don’t be reactive. You aren’t going to like the decision, but review the reasons as objectively as possible. Then put it away for a few days and read the letter again.

Call the Benefit Analyst (BA) if you still don’t understand why the claim was denied. This is not a time to be rude. Stick with the facts. Does the insured actually need assistance with two or more Activities of Daily Living (ADLs) as defined in the contract?

A good, and experienced, BA will already have called and talked to you about potential claim decline and why. That is your opportunity to provide objective medical evidence, or tell the BA where to find it.

What to Do if You Disagree with the Decision

If you still disagree, begin with the appeal process that also should be outlined in the letter. Your insurance company usually will want an appeal in writing and it should include the reasons why you feel the decision is incorrect. Again, stick to the facts related to why the claim was denied. Once you’ve addressed those specific issues, then you can include other information that may be pertinent to the insured’s overall need for assistance.

Please understand that talking about Incidental Activities of Living (see Part 1) will not help the case for benefit eligibility. It can’t be said often enough that the contract you bought is specific about eligibility. You must need assistance with two, or more, Activities of Daily Living to be benefit eligible.

The BA who made the decline decision did not make it alone and will not be the one to review the appeal.

State Insurance Departments

If all else fails and you still believe the decision is not a good one, you can access your State Insurance Department’s complaint process. Please do not go here just because you don’t like the decision. Your insurance company will provide the facts they used to make the decision to the State (they have already provided it to you) and the State will respond. I can say from experience that a complaint filed with the state does not mean that the denial will be automatically overturned. As always, the facts will be reviewed by all concerned.

Going through a claim decline is upsetting. But it should not be a reason to cancel your policy or hate all insurance companies. It can be a tool as you now have a better understanding about how to properly access benefits in the future.

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Part 1: 5 Tips for Submitting a Long-Term-Care Claim

Advice from a retired LTC Senior Benefit Analyst

canstockphoto3927561There are a number of reasons why a long-term-care claim (LTC) process could go off the rails. Here are some tips about how to begin the process, whether you are the claimant, family member, friend, or agent. Most issues can usually be resolved with timely and courteous communication.

  1. Call the insurance company as soon as services are necessary. Do NOT delay until your waiting period (if any) has been satisfied. Claim immediately even if Medicare will be billed for nursing home services, or home health care. Those Medicare days may count towards the policy waiting period even if they are not reimbursable. A claim could be delayed or declined because it can be difficult to reconstruct details after several months. For instance, the insured might have been eligible at the time of services, but has since recovered. Claim forms submitted by the care provider will then show the insured as not currently benefit eligible. Those types of claims are particularly difficult to review and find the necessary eligibility documentation.
  2. Discuss policy requirements at first contact. LTC contracts will have specific definitions of Activities of Daily Living (ADLs) and how benefits are triggered – most often by the need for ADL assistance. ADLs can be some combination of bathing, dressing, toileting, continence, eating, and transferring. Maybe the insured can’t buy their own groceries, clean house, prepare a meal, or do laundry, but these are defined as incidental activities of daily living (IADLs) and by themselves do not trigger benefits. A claimant must be benefit eligible first due to the need for ADL assistance before IADLs can be considered.
  3. Fax or mail HIPAA documents (Durable Power of Attorney for financial matters; and/or Power of Attorney for Healthcare; and/or Authorization to Release Information) to the claims department ASAP. If you don’t have formal documents, ask what is acceptable. Insurance companies and healthcare providers take HIPAA very seriously. It may seem logical that a spouse or relative of the insured should automatically be privy to HIPAA-protected information, but that is not necessarily true –  unless there is specific HIPAA authorization.
  4. If claim forms are required, send them in right away. Dropping a form at a doctor’s office or an LTC facility does not guarantee timely delivery to your insurance company, as paperwork can, and often does, fall behind. Be prepared to follow up. As a courtesy, an insurance company will sometimes follow up on your behalf. But remember, the contract is between the insured and the insurance company. You are responsible for meeting claim requirements, which also could include submitting bills.
  5. Read your policy.Too many people don’t. Ask your insurer if you don’t understand. Are assisted living facilities covered? If not (as on some older policies), are there circumstances when they might be? If the policy provides home care benefits, is an independent, unlicensed caregiver reimbursable, or must the care be provided through a home healthcare agency? Does your policy cover care provided by family members? What are the policy exclusions?

Arm yourself with facts and try to remember that customer service representatives, benefit analysts, and intake departments are human beings who also have parents who are aging. Give them a chance to help because they want to.

See Part 2

See Part 3

See Part 4