NEW CLAIM & PRE-CLAIM SERVICES
STAGE 1 - Detailed Policy Contract Analysis
Upon scheduling a free consultation, you will be asked to email or fax us a copy of your insurance policy to prepare us to best serve you. If you don't have a copy, we'll work with your insurer to obtain one at no cost. If you choose to obtain one yourself, we advise you to do so only in writing. We caution you to avoid contacting your insurer over the phone. Their receptionists are trained to ask you questions regarding you're asking for one and what you intend to use it for. What you say can and will be creatively used against you to minimize your claim.
Our policy contract analysis goes far behind a simple review. Over the past 40 years, hundreds of thousands of variations of LTC insurance policies have been written. Unlike any other type of insurance policy, LTC policy terms and language are non-standardized and virtually unregulated. Our team has devoted thousands of hours of legal research to studying LTC insurance claim trends and deceptive practices.
The purpose of our analysis is to enable us to determine if you are pre-qualified to submit a claim and helps us craft creative strategies to maximize your reimbursement and expedite payment. We do all the heavy lifting and prepare to explain your options and likely reimbursement figures in plain English during your consultation.
STAGE 2 - Retroactive Reimbursement & Elimination Period Financial Planning
Collection of retroactive reimbursement and financial planning to reduce or prevent expenses during elimination periods are the two most overlooked ways to ethically harvest financial rewards from your policy. For policyholders who have been fortunate enough to get their claims approved on their own, they are almost always unaware of the incredible financial rewards they may have been eligible for had they worked with us. It serves as an example that what you don't know can cost you dearly.
Retroactive Reimbursement refers to expenses incurred before filing a claim that the policyholder is entitled to a refund for. "Sunset provisions" are virtually non-existent within LTCi contracts This means there is generally no limit on how far we can look back and collect reimbursement. Often it's possible to recover reimbursement for expenses that you wouldn't typically think of, such as a spouse or other family member caring for the policyholder. Our experienced nurses expertly examine medical records and collaborate with care providers to ensure that the language and coding of records aligns with the policy contract language identified by our legal department. Our nurses come from a variety of direct patient care settings and speak the language of providers. In turn, providers enjoy working with us because they know we make efficient use of their time. At the end of the day, they appreciate that the care they ordered is being paid for and are happy that their patients are satisfied and being well taken care of.
The goal of medical records examination and collaboration with care providers is to identify past changes in health that can serve as substantiating evidence to trigger coverage. Once a point in time is established, we then use sound accounting-based practices to calcuate the retroactive reimbursement amount. The result is a detailed and persuasive demand for swift retroactive reimbursement that accompanies your claim submission.
For even the most basic policies, retroactive reimbursement can exceed $20,000. This alone can pay for our services many times over. Note that retroactive payments can be remarkably higher for policies with higher limits.
Elimination Period Financial Planning refers to reducing or preventing expenses and financial loss during the benefit elimination period. An elimination period is a contract term that refers to the time period between a medical trigger (two or more impaired Activities of Daily Life) and when the insurer will begin reimbursement. It is sometimes referred to as a 'waiting, 'qualifying,' or 'deductible period. Before the insurer will pay benefits, you are required to pay for all care expenses. You are not eligible for reimbursements until you incur expense the month after the period ends (typically 60-90 days).
Through careful planning and with a strategy similar to obtaining retroactive reimbursement, we are often able to identify a point far before the elimination period during which two or more Activities of Daily Life were effected). This results in eliminated expenses during the time period that the insurer would deceptively tell you that you're entirely responsible for.
Retroactive Reimbursement & Ellimination Period Financial Planning are two ethical, legal, and technical strategies for both refunding you money and saving you money during the 60-90 day elimination period. Insurers will not inform you that the methods are available to you and will not give you instructions on how to succesfully implement them. It is technically possible for an unrepresented policyholder to succeed with these strategies. However, because of the significant dollar value involved, they heavily scrutinize submissions. If they find one single error, not only will you be denied these two options, but your entire claim will likely face unwaranted delay.
STAGE 3 - Claim Optimization & Submission
Expert claim preparation is essential for swift and maximized reimbursement. Policy contracts and the varying insurers' claims handling procedures deviate wildly. Our legal department has spent years studying LTCi contracts and associated litigation involving contract interpretation, claims handling, and deceptive strategies used to delay, deny, and under-reimburse claims.
Utilizing our comprehensive policy analysis and our team of nurses who collaborate with care providers, we work to ensure that all care needs and expenses are precisely worded and coded to match the insurers requirements and to avoid scrutiny. Coming from healthcare and healthcare law settings, we know just how deeply providers struggle with the burden of matching their care recommendations and advice with insurance policies that are designed to make coverage extremely difficult. Health insurance claims documentation is difficult enough. LTC insurance claims are exponentially more challenging. We make it easy for providers to produce the right documentation the first time.
We've built a reputation with insurers for fair and transparent dealing. Insurers work with us because our submissions are structured and crafted to avoid obstacles or any legitimate barrier to approval and reimbursement. Our claims come with explicit instructions and outlined expectations for swift and full reimbursement. All claim submissions are medically and legally compliant, are complete, and are what the insurance industry deems "clean."
STAGE 4 - Early & Robust Intervention
We do not view insurers as our enemies, but rather as a party whose financial interest are directly opposed to yours. Our job is to constructively hold them accountible. LTC insurance claims departments utilize aggressive "cost containment systems," better known as claim minimization programs. Claims are handled by third parties who are given narrow, explicit instructions not to share information that would assist you in obtaining full reimbursement you're entitled to. Their job is to keep the policyholder in the dark and lull you into believing they have done everything they can for you.
Claims are minimized in the form of delays, denials, and low artificially low reimbursement. We utlize the opposite approach: a claim expediting and maximization system. One of the hallmarks of LTCAE is our consistency, follow-up, and ability to quickly influence insurers to correct course when if they stall or attempt to deny a claim. We monitor the progress of each claim, know the red flags that predict unnecessary delay, and we know all the claim handling tricks. We act fast to extinguish unwarranted scrutiny. More often than not, our efforts prove to be seem as a strong deterent to deceptive practices and insurers know our mission is not to attack them.
Rather than wage an all-out legal offensive, our intervention strategies focus on enforcing policy contract compliance. Swift and effective spotting and resolution of issues is a much more efficient and effective tactic for ensuring timely and full payment. In a manner policyholders are not typically able to, we are able to access decision-makers who have the authority to approve claims and move them along. We walk them through exactly what needs to get done and hold them accountable to our expectations.
STAGE 5 - Monthly Billing Management
Claims do not renew themselves. They require monthly submission of bills with the highest level of precision. They must be structured under the same standards as the original submission. This includes detailed care notes, proper coding, and language that precisely matches the policy language. The risk of delays, denials, and under-reimbursement does not end after the first approval. Insurers make every effort to deny coverage at every turn of the road. This particularly applies if you are receiving substantial reimbursement. Our systems and strategies ensure that clean and complete claims are submitted every month to keep reimbursement coming.
STAGE 6 - Unlimited Claim Re-certifications
Insurers have the legal right to periodically require re-certification of claims. This includes their own nursing or medical evaluations. The evaluators can either be employed directly by the insurer or hired as a third party. Insurers like to misrepresent third party evaluators as "independent." This couldn't be further from the truth. The simple adage "follow the money" is an easy test anytime you're dealing with an evaluator you have not hired yourself. If an individual is paid by the insurer, their duty and loyalty is to the insurer. Recently disclosed industry records revealed that 93% of insurers' evaluators agree with claim denials or reductions.
This often comes after you've had success in getting your initial and monthly claims approved. The longer you're on claim and the more money you're collecting, the higher the likelihood and scrutiny of a review. YOUR nurses at LTCAE are well-equiped to collaborate with care providers to provide enhanced and verifiable documentation of continuing care needs in order to prevent denials or reductions. You and your care providers alone have the right to determine the care that is best for you. Not the insure company.
Families are often shocked to learn that insurers also routinely attempt to interact with vulnerable policyholders in person or by phone when they're alone. When a policyholder is receiving home care, court records have revealed that insurers often employ private detectives to discover when no one else is at the home. A nurse then knocks on the door and assures the policyholder that they're there to help. The questions asked by the nurse are biased by nature and intended to get the policyholder to misrepresent their needs or omit details that they may find confidential or embarassing.
When you hire us, we inform the insurer in writing that they prohibited from speaking or meeting with the policyholder alone. Our background in elder abuse and financial exploitation of vulnerable populations makes us well-equiped to disarm attempts to harm the policyholder in this manner. We inform the insurer that the policyholder will comply with the law and allow re-certification exams if deemed necessary, but that the insurer is not permitted to contact the policyholder unless he or she is with either us or a family representative (at your choosing).
STAGE 7 - Persistent Follow-Up & Client Satisfaction
Our persistent follow-up doesn't apply only to insurers. We never lose focus from our mission to serve clients and grow their opportunities to reap more financial rewards from their policies. You should be receiving a generous return on your investment. Our systems and cutting edge technology are second to none. However, we embrace a humble approach to relentless improvement and encourage all feedback from clients. When your care needs change or you incur a new expense from your care providers that you'd like to see reimbursed, we encourage you to reach out to us at your earliest convenience. We'll gather information from you and then look for creative, ethically sound opportunities to get the expense covered. A key to our success is actively and compassionately listening to our clients and making sure their needs come first.