As our population ages, some of us
It’s particularly important to focus on a few key areas early on to ensure an appropriate outcome. See below for what LTC claims analysts should remember at the onset of a claim:
Speak directly with the claimant (customer) first.
The first telephone call to the claimant often presents an opportunity for education that can be key for the ongoing success of the claim. It’s important to review the policy provisions with them directly – such as what needs to be in place to meet benefit eligibility, and what the policy will and will not cover – so they and their family members are clear on where they stand.
While it may seem more convenient to conduct the call with a family member in some cases, it is the customer’s claim and policy; they should be the primary contact and driving force behind it.
Know who is authorized for medical power of attorney before having the call.
There are instances where the claimant will be unable to engage in the management of their claim. They may be hospitalized or have a cognitive impairment severe enough that they would not understand what is being discussed. When this is the case, the claims analyst is responsible for ensuring the person they are speaking with has authority to do so. A thorough review of power of attorneys (POAs) or other authorizations is important. Be sure to ask these questions:
• Does the person you are speaking with have only the power to make medical decisions, or do they also have the power to make financial decisions on the claim?
• What needs to be in place, and are those things in place, in order to enact the POA?
It is important to remember this is a trying and stressful time for the claimant and their family. In order to be eligible for LTC benefits, they are at a point where they cannot take care of their basic needs by themselves.
Take the time to listen. While you have your bullet points as an analyst to cover in the initial call and a million other things to do on your desk, pause, take a breath and allow the claimant or their family member to talk about what they are going through. Just listen.
A key role of the claims analyst is that of an educator.
Educating the claimant and family member regarding policy language around the definition of the loss of Activities of Daily Living or a Cognitive Impairment is an important first step. It may seem obvious, but it can be time well spent to spell out what daily activities mean.
For example, eating is defined as the act of getting food that is placed in front of you into your mouth – not the ability to prepare a meal. Or consider that assistance with bathing is defined as having someone with hands on you or standing within arm’s length from you – not having someone within shouting distance in case you fall.
Establish appropriate care per the policy.
It is the claims analyst’s responsibility to understand if the policy requires that care is provided by a licensed home health agency, assisted living facility or skilled nursing facility. Each policy has a definition for the level and type of care needed to meet benefit eligibility.
Frequently the claimant or their family sees the word “licensed” and assumes that if a caregiver is a licensed CNA, LPN or RN, this is sufficient. However, in the majority of the cases, this is not enough. The caregiver would be required to be an employee of an agency.
This can be a difficult conversation when a care provider has been in place already and trust has been developed between the claimant, their family, and the caregiver. However, it is important to clarify up front before the claim is further along in the process.
Conduct a detailed call with the care provider to determine if the level of care is the same as what is reported.
Speaking with the caregiver can often be overlooked until the point of making a claim decision. Ideally, it should be completed as soon as possible during the initial review of the claim. Here are some questions to ask to better understand their role:
• How often are they providing care?
• If the insured is claiming a cognitive impairment that puts them at risk for health and safety, how often is the caregiver checking on them and is it an appropriate frequency?
• If the insured is indicating they need assistance with toileting, but a caregiver is there only in the mornings, how are they managing the rest of the day?
Answers to these questions help put the puzzle pieces together for the right decision on a claim. It is important to remember this is an extremely difficult time in both the insured’s and their family member’s life. Ensuring the above steps are taken at the beginning of a Long Term Care claim will allow for the most appropriate decision to be made on the claim. In addition, it will allow for solid and proper management of the claim going forward.