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1 LTC Underwriting to Claims Pam Kreager, RN - Director of Clinical & Quality Standards, Univita Joanne Masters, RN - LTC Risk Manager, MetLife Long-Term.

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Presentation on theme: "1 LTC Underwriting to Claims Pam Kreager, RN - Director of Clinical & Quality Standards, Univita Joanne Masters, RN - LTC Risk Manager, MetLife Long-Term."— Presentation transcript:

1 1 LTC Underwriting to Claims 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 4 th – 6 th, 2011 Objects in the Rear-View Mirror Not Always as They May Appear

2 2 Underwriting - The Journey ◊Risk assessment ◊Agents ◊Cycle time ◊Balanced risk pool ◊Production ◊Declines ◊Requirements

3 3 Claims – Road Risks & Mitigants ◊All cases have inherent risks ◊Claims versus Underwriting View ◊A look in the rear-view mirror

4 4 Underwriting View: Case # 1 ◊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

5 5 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?

6 6 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?

7 7 Underwriting View: Case # 2 ◊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

8 8 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?

9 9 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?

10 10 Underwriting View: Case # 3 ◊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)

11 11 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?

12 12 Claims View: Case # 3 ◊Claimed 6 month post effective date ◊Diagnosis: CVA ◊Right sided weakness ◊Dysphagia  Lessons learned in the rear-view mirror?

13 13 Underwriting View: Case # 4 ◊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

14 14 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?

15 15 Claims View: Case # 4 ◊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?

16 16 Underwriting View: Case # 5 ◊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

17 17 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?

18 18 Claims View: Case # 5 ◊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?

19 19 Underwriting View: Case # 6 ◊36 y/o female; single ◊Works full time ◊Group Policy Guaranteed Issue (no underwriting)

20 20 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?

21 21 Claims View: Case # 6 ◊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?

22 22 Underwriting View: Case # 7 ◊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

23 23 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?

24 24 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?

25 25 The Road Less Traveled ◊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

26 26 QUESTIONS ?


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