Advice from a retired LTC Senior Benefit Analyst
There 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.
- 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.
- 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.
- 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.
- 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.
- 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