LTC Underwriting to Claims
Objects in the Rear-View Mirror
Not Always as They May Appear
Pam Kreager, RN - Director of Clinical & Quality Standards, Univita
Joanne Masters, RN - LTC Risk Manager, MetLife
Long-Term Care International Forum
Albuquerque, New Mexico
May 4th – 6th, 2011
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Underwriting - The Journey
◊ Risk assessment
◊ Production
◊ Agents
◊ Declines
◊ Cycle time
◊ Requirements
◊ Balanced risk pool
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Claims – Road Risks & Mitigants
◊ All cases have inherent risks
◊ Claims versus Underwriting View
◊ A look in the rear-view mirror
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Underwriting View: Case # 1
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68 F; single
App, PHI, APS
Passed cognitive screen
5’5” 196#
Ulcerative colitis - stable on one med
Recent MD letter - not candidate for jury
duty d/t ulcerative colitis - can't sit for 2
hours
Chronic mildly ^ liver enzymes
(consistently 1.5x normal)- secondary to
colitis Rx
Depression 2 years ago - loss of mother &
sister; current low dose Zoloft
Pancreatitis 7 years ago
PHI reports active and independent
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Road Hazards
◊ Is there enough information; should
we make a U-Turn?
◊ Any concerns or Bumps in the Road?
◊ What (if anything) more is needed –
STOP or GO?
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Claims View: Case # 1
◊ Claimed 14 months post policy effective date
◊ Diagnosis: Biliary Cancer with Mets to Liver
Lessons learned in the rear-view mirror?
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Underwriting View: Case # 2
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66 M; spouse applying
App, APS & PHI
Passed cognitive screening
5’10” 169 #
Works as consultant 10-12hr wk, walks dog daily
MD q 3 months, BP normal
Hernia repair 1 mo ago - full recovery
Low back pain - DDD - hydrocodone 1-2x/mo
HOH, erect, steady, some stiffness noted in neck
1 yr ago APS note: “d/c'd lipitor b/c couldn't think
straight - c/o memory problems since being on it
& better off it. Now on Vytorin”
◊ Borderline DM - diet; gluc 96, A1c 5.9
◊ Chest pain 1.5 years ago - normal stress test
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Road Hazards
◊ Is there enough information; should
we make a U-Turn?
◊ Any concerns or Bumps in the Road?
◊ What (if anything) more is needed –
STOP or GO?
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Claims View: Case # 2
◊ Claimed 10 months post effective date
◊ Diagnosis: Frontal Temporal Dementia
◊ Claims APS:
– 2-3 year history of insidious cognitive decline characterized primarily by
short term memory impairment
– MD notes client denies cognitive difficulties ,poor historian doing best
to cover up difficulties. Has not worked F/T in 2 years, although has
maintained some degree of involvement with business
– Spouse notes symptoms worsened over past several months with
changes in emotions & personality
– Cognitive testing:
• Performance uneven across tasks. Ranged from severe executive dysfunction
to fully preserved functioning of language based memory.
• Serial word learning: amount of learning & the recall within normal limits.
• Tests & observations suggest dementia advancing to moderately severe.
• Scores inconsistent with a diagnosis of dementia of Alzheimer's type-failed
to ID constructional dyspraxia & preservation of language-based memory
was striking
• MRI had some abnormalities
Lessons learned in the rear-view mirror?
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Underwriting View: Case # 3
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58 F; spouse applying
App, PHI, APS
Passed cognitive screen
4’11” 152#
HTN age 20; takes Diovan 80 mg & Lotrel 10 mg. qd
- MD q 6 mo
BPs : 118/78, 160/96, 150/96-diovan ^ to 2 qd,
148/94, 138/92, 120/84- weakness of arms & legs
since ^ diovan- decreased to 1 qd, 138/86 (last BP
178/82 - sinus infection w fever)
^ cholesterol x 15 years - Lipitor
Sleep apnea x 5 years - CPAP intermittent
Mild increase bilirubin - stable labs - 2.2 & 2.1
(norm 0.3-1.9)
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Road Hazards
◊ Is there enough information; should
we make a U-Turn?
◊ Any concerns or Bumps in the Road?
◊ What (if anything) more is needed –
STOP or GO?
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Claims View: Case # 3
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Claimed 6 month post effective date
Diagnosis: CVA
Right sided weakness
Dysphagia
Lessons learned in the rear-view mirror?
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Underwriting View: Case # 4
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26 M; single
Works – athlete
App, PHI
5’7” 140#
3 years ago torn cartilage L knee repaired, no sequelae
◊ Bruised heel 6 mo ago- treated w
Celebrex x 2 weeks. Full recovery
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Road Hazards
◊ Is there enough information; should
we make a U-Turn?
◊ Any concerns or Bumps in the Road?
◊ What (if anything) more is needed –
STOP or GO?
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Claims View: Case # 4
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Claimed 6 months post effective date
Diagnosis: C 6-7 spinal cord injury
Racing accident
Paralyzed from neck down
Lessons learned in the rear-view mirror?
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Underwriting View: Case # 5
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74 F; spouse applying; walks, golfs, drives
App, APS, F2F
Passed cognitive screen
5'6" 135#
4 yrs ago: allergy clinic - asymptomatic; FEV1 70; O2 sat 96 %; mild allergic rhinitis & intermittent
asthma; bronchiectasis & recurrent pulmonary infiltrates managed by pulmonologist
OP - fosamax & caltrate D
3 yrs ago f/u pulmonologist for bronchiectasis. Stable. Nodular pulmonary infiltrates. Had a URI w
antibiotics; CT chest-continued infiltrates R middle lobe. New small nodules & infiltrates LLL may
represent smoldering infection, but asymptomatic - observe
2 yrs ago CT w infiltrates stable in location & appearance. Pattern consistent w bacteria infection,
no symptoms; O2 sat & PFTS wnl Discharged from pulmonologist - f/u with PCP
18 mo ago - back pain. Celexa – daughter dying
1 yr ago - Daughter died- Celexa has helped, sciatica better
6 mo ago – fatigue, dyspnea on exertion. Stress w daughter & mother's deaths. Suspect
deconditioning, but w past hx, pulmonologist: CT chest w bronchiectasis similar to previous. Few
adjacent subcentimeter peripheral opacities-probably inflammation. FEV 1 = 68% , FVC = 73%.
Bronchodilator B4 walking
Case declined - bronchiectasis & PFTs
Pulmonologist letter: Referred 5 yrs ago for bilateral pulmonary infiltrates, chronic cough &
phlegm. Symptoms transient. Never developed chronic respiratory symptoms. No significant
change in nodules or infiltrates in last 5 yrs, PFTs reveal mild-mod airflow obstruction; active
lifestyle w/o restriction in activities; no evidence cancer or progressive infection
Accepted on appeal
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Road Hazards
◊ Is there enough information; should
we make a U-Turn?
◊ Any concerns or Bumps in the Road?
◊ What (if anything) more is needed –
STOP or GO?
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Claims View: Case # 5
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Claimed 22 months post effective date
Diagnosis: Lymphoma
Has terminal NH Lymphoma of the lung
Needs narcotics which are causing cognitive
problems
◊ Needs assistance with all ADLs
◊ Expected to continue to decline
Lessons learned in the rear-view mirror?
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Underwriting View: Case # 6
◊ 36 y/o female; single
◊ Works full time
◊ Group Policy Guaranteed Issue
(no underwriting)
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Road Hazards
◊ Is there enough information; should
we make a U-Turn?
◊ Any concerns or Bumps in the Road?
◊ What (if anything) more is needed –
STOP or GO?
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Claims View: Case # 6
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Claimed 1 month post effective date
Diagnosis: spinal cord injury/quadriplegia
Resides at home with mother
Was in MVA 5 years ago & has C5 spinal cord injury
Currently receiving home care
Power chair dependent
Needs assistance with bathing, dressing, transferring,
toileting, & food set-up to eat
◊ Currently working
Lessons learned in the rear-view mirror?
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Underwriting View: Case # 7
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74 M; single (widow x 10 yrs)
App, APS, F2F
Passed cognitive screen;
5’9” 203#
Elliptical machine 3x/wk, mows cemetery
Hypertension - BP 130/86, stable
No regular labs, but recently done wnl except slightly low Na
& K+. Rx’d K+.
◊ MVA 2 yrs ago w nose laceration. Distracted & drove into
ditch & creek. Remembers circumstances of accident & able
to get out of car on his own. ER: no ETOH, cognitive or other
problems
◊ Craniotomy 10+ yrs ago - fall from 8 ft high; wrist fracture
◊ F2F: Retired 10 yrs ago; rates health very good & same as a yr
ago; daughter does laundry; living conditions & home
unkempt. States capable of cleaning & laundry. Sees no
need to clean house or dress up. Several teeth missing.
Shaven & hair combed; BP 118/62, PCP LOV 1 mo ago;
asthma for yrs - no current sx; occ. fatigue d/t old age;
kyphotic, ambulation wnl
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Road Hazards
◊ Is there enough information; should
we make a U-Turn?
◊ Any concerns or Bumps in the Road?
◊ What (if anything) more is needed –
STOP or GO?
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Claims View: Case # 7
◊ Claimed 11 months post effective date
◊ Diagnosis: Multiple fractures; contusions,
internal injuries
◊ MVA
◊ Pulled out in front of another vehicle
Lessons learned in the rear-view mirror?
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The Road Less Traveled
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Making the underwriting determination
Appropriate level of investigation and risk
Young, actively at work risks
Occupation/leisure activity hazards
Flags - evaluate
Use the First Aid Kit/Tools
 Cognitive screens
 Pharmacy screen
 MIB
 Stroke risk profile
 Specialty records
◊ Evaluate claims with the mirror in mind
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QUESTIONS?
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