9 Long-Term Care Insurance Claim Whisperer Secrets

That can hurt families that are trying to show that elderly parents or other loved ones are eligible for benefits, Rinehart said.

Another common problem, he said, is that LTC providers and other people unfamiliar with stand-alone LTCI often assume that the coverage eligibility period begins when the insured enters a facility, or begins receiving extensive home care.

In reality, he said, the eligibility determination clock for the typical policy starts ticking when the insured begins to need regular help with two activities of daily leaving (ADLs).

A failure to understand that the clock starts ticking when the insured has trouble with two ADLs, and a failure to document the initial problems with ADLs, may mean that the insurer will start paying benefits many months later than the benefits stream really should start, under the terms of the policy, Rinehart said.

5. The ‘insurers’ that Family Solutions for Care works with are usually not the insurers.

Rinehart said his experience is that most insurers have hired a “third party administrator,” or outside company, to process claims.

6. Policy variations are not actually that big of a problem for Family Solutions for Care.

Rinehart said he has heard that consumers have used about 400,000 LTC benefits forms and form variations.

In theory, simplifying the forms could simplify Rinehart’s life.

In the real world, Rinehart said, most of the LTCI and LTC hybrid benefits administrators want roughly the same kinds of documentation.

Simplification might help the claim administrators reduce costs, but it would not do all that much for the patient advocates, he said.

7. Movement away from the age of the facsimile machine might help a lot.

Offices outside of the worlds of law, medicine and insurance are moving away from routine use of fax machines.

Rinehart said his own world still revolves around fax machines.

Medical offices and insurance claim administrators still want faxes, possibly because of data security considerations and other compliance considerations, he said.

“You have to follow up,” Rinehart said.

If Family Solutions for Care faxes a 180-page document to a claim administrator, and one important page is missing, the insurer is probably not going to say that something is missing, Rinehart said.

8. Easier access to health records in general might help.

Federal regulators at the Centers for Medicare and Medicaid Services have tried to give patients easier access to their health records, but, in the real world, getting records from a provider still takes an average of about seven telephone calls, Rinehart said.

9. Diagnosis codes reflecting a patient’s need for help with activities of daily living might help.

Rinehart said he thinks that, if doctors could assign patients standardized, respected codes that would reflect those patients’ need for long-term care services, that would simplify the LTCI claims process quite a bit.

A doctor can use the ICD-10 system to classify a patient as having had a heart attack, or a broken arm.

One reason Family Solutions for Care has to spend so much time getting and faxing medical records is that gathering a large file of records is the only way to document how much care a patient needs, Rinehart said.

— Read The Largest Individual LTCI Claim of 2018, on ThinkAdvisor.

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