LTC Claims Services Presented by Lori Watson Director
LTC Claims Services Presented by: Lori Watson, Director Claims Practices and Quality Assurance Leader Long Term Care Claims April 2, 2012 FOR PRODUCER/AGENT INFORMATION ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC. © 2010 Genworth Financial, Inc. All rights reserved. Company Confidential
The LTC Claims Process – Our People • Over 350 LTC Claims Associates To Fulfill Our Promise! Dedicated CA Team! • Over 3000 Years Of Relevant Claims Experience – External Hires From LTC Industry – Internal Development • People Development Key Priority – – – Training Professional 6 -Week Classroom Training 4 -Month Post Training Mentor Program Medical Terminology Training LTCi and LTCP Certification Programs FOR PRODUCER/AGENT INFORMATION ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC.
The LTC Claims. Overview Process Claim Initiation Intake Care Coordination • Dedicated Toll Free Telephone Coverage – More than 50, 000 inbound calls a month – Toll-Free Phone Number: 800 876. 4582 – Hours: 9: 00 AM - 8: 00 PM Eastern Time, Monday - Friday • 100% Image - Inbound / Outbound Correspondence • Policy & Benefit Expertise on First Call FOR PRODUCER/AGENT INFORMATION ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC. 2 Initial Eligibility Ongoing Management
Overview The Claims Process Claim Initiation Intake Care Coordination Initial Eligibility Ongoing Management Initial Call to Insured is Placed within 48 Hours of Receipt of Notice of Claim: • • Who we are, what is our role and that of the Care Coordinator Local Care Coordinator will call Insured to schedule comprehensive individualized face-to-face assessment Discuss current long term care needs and services Discuss current care in place Offer help in finding local long term care providers and services Offer help in arranging long term care Provide contact information to Insured and family FOR PRODUCER/AGENT INFORMATION ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC. 3
Overview The Claims Process Claim Initiation Intake Care Coordination Initial Eligibility Ongoing Management What is Care Coordination? An administrative structure that is responsible for: • Gathering information and assessing needs for long term care and services • Offering assistance in the completion of claim forms • Developing and implementing initial and ongoing plans of care • Identifying and locating care provider resources of the highest quality and negotiating rates • Assisting in obtaining necessary long term care and services • Providing on-going monitoring of care needs and providers FOR PRODUCER/AGENT INFORMATION ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC. 4
Overview The Claims Process Claim Initiation Intake Care Coordination Initial Eligibility Ongoing Management Who are the Care Coordinators? • Come through national vendors who have networks of qualified care coordinators specializing in providing functional assessments and care coordination services • Knowledgeable about community long term care and services resources • Have solid clinical backgrounds – all registered nurses • Have been trained and chosen for their considerable expertise in: • Conducting functional and cognitive assessments, developing and implementing plans of care • Identifying and monitoring all types of long term care and services • Are not and do not act as “gatekeepers” nor are they care providers FOR PRODUCER/AGENT INFORMATION ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC. 5
Overview The Claims Process Claim Initiation Intake Care Coordination Initial Eligibility Ongoing Management When does Care Coordination Start? • Begins at the time Claims Services is notified of a claim • Continues throughout the duration of the claim by: • Providing individual guidance and assistance during a very stressful time • Ensuring the provision of appropriate care and services needed to remain as safe and independent as possible • Identifying and maximizing the potential for regaining independence • Evaluating the care services on an on-going basis, revising the plan of care as needed FOR PRODUCER/AGENT INFORMATION ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC. 6
Overview The Claims Process Claim Initiation Intake Care Coordination • Face-to-face Assessment Used As a Tool in Establishing Insured Benefit Eligibility • Attending Physician and Care Providers are Consulted • Benefit Eligibility Determined • “Care Call” conducted for Indemnity Policyholders • No Denials Without Second Tier Review FOR PRODUCER/AGENT INFORMATION ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC. 7 Initial Eligibility Ongoing Management
Overview The Claims Process Claim Initiation Intake Care Coordination • Benefit Analyst = Single point of contact – For all claims matters – Help for caregivers and support for family • Monthly Communication with Insured • Efficient and Reliable Monthly Payment Process (EFT, etc. ) FOR PRODUCER/AGENT INFORMATION ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC. 8 Initial Eligibility Ongoing Management
Our Experience 162, 700 Claims Paid • Over $7. 7 Billion dollars in Benefits Paid Through 12/11 • Youngest Claimant: 27, Oldest Claimant: 103 • Longest Claim: 18. 7 years • $1. 2 Million Is Largest Single Claim • 71% Of Claim Dollars Have Been Paid to Female Claimants • Genworth Pays Out $4. 3 Million in Benefits Every Business Day • 50% of All Claim Dollars are Paid To Claimants With Mental Disorders including Dementia As of 12/31/2011, all GNW products LTC Claims Experience Data – Company Confidential 9
GNW Reimbursement Claims Benefit Usage Since Inception First Benefit Home Health Care Assisted Care Facility Nursing Home Latest Benefit 71% 13% 16% 64% 19% 17% Claim Close Reason Since Inception Death Recovery Exhaust Home Health Care Assisted Care Facility Nursing Home 53% 63% 76% 41% 10% 8% 6% 27% 16% All Claims 59% 30% 11% *Long Term Care Claims Experience Data for Genworth Life Insurance Company and affiliates – December 1974 through December 31, 2011 LTC Claims Experience Data – Company Confidential 10 Company Confidential. For producer use only. Not for public use or distribution.
GNW Reimbursement Claims Age atat Claim Age Claim • Average Age of Claimant = 78. 7 Years • Married women tend to claim at an earlier age than single women and men *Claimant ages rounded to the nearest 5 year age group. *Long Term Care Claims Experience Data for Genworth Life Insurance Company and affiliates – December 1974 through December 31, 2011 LTC Claims Experience Data – Company Confidential 11
GNW Reimbursement Claims Claim Duration Type of Care 43% of claims last less than one year due to: < 1 year • short recoverable illness • sudden terminal illness • Single use of non-care giving benefits (equip, training, etc) > 1 year Home Health Care 84% 48% Nursing Home 10% 23% Assisted Living 6% 29% Diagnosis < 1 year The average length of claims that last more than a year is 3. 9 years 15% of claims will last more than 5 years Musculoskeletal 27% 14% Cancer 30% 5% Cardiovascular 14% 17% Dementia 12% 46% Respiratory 5% 5% Brain/CNS 5% 10% *Long Term Care Claims Experience Data for Genworth Life Insurance Company and affiliates – December 1974 through December 31, 2011 LTC Claims Experience Data – Company Confidential 12 > 1 year
LTC Claims Cognitive Trending Data • New Claims activity for Reimbursement & Indemnity GNW only products. • The “All Other Cognitive Claims” category includes such diagnosis as: Manic Depression, Organic Brain Syndrome, and Bipolar Disorder. *Long Term Care Claims Experience Data for Genworth Life Insurance Company and affiliates – January 2004 through December 31, 2011 LTC Claims Experience Data – Company Confidential 13
Where People Receive Care… Transitions 71 Home 12 Facility 2 Home 2 100 29 Facility 8 80 people never transition Home 15 people transition once 1 Facility 5 people transition twice • Younger people transfer less to Facilities • Most people do not transition from where they receive their initial care • No gender differences seen in analysis • Later generation LTC products – higher transfer rates to HHC • Married claimants leave home less often • A misconception that this is a common transition (HHC - ALF – NH) *Long Term Care Claims Experience Data for Genworth Life Insurance Company and affiliates – December 1974 through December 31, 2011 LTC Claims Experience Data – Company Confidential 14
GNW Reimbursement Claims Diagnosis – Percentage of Claims and Average Cost Single Women Married Women Single Men Married Men 38% of All Claims 27% of All Claims 11% of All Claims 24% of All Claims 31% 32% $117 K Dementia Cancer 12% Fractures - other 6% 14 K Stroke 6% 87 K Osteoarthritis COPD 5% 4% $113 K 78 K 65 K 13 K 5% 6% 4% 78 K 3% 2% 2% 17 K 7% 74 K 7% 62 K 2% 13 K 2% 74 K 67 K 4% 58 K 3% 38 K 59 K 5% 50 K 4% 41 K 67 K Spinal Stenosis 2% 74 K 2% 22 K 2% 21 K Hip Replacement 2% 12 K 1% 12 K Parkinson's 2% 123 K 3% 21 K 2% 20% 62 K 3% 3% $84 K 19 K 16% 91 K Congestive Heart Failure Hip Fracture $93 K 18 K 16% 23 K 31% 30% 71 K 2% 68 K 2% 51 K 1% 20 K 1% 18 K 1% 14 K 5% 118 K 108 K 6% 90 K Bone and Joint Disorder 1% 39 K 1% 36 K 1% 40 K <1% 55 K Knee Replacement 1% 10 K 1% 9 K 1% 14 K 1% 10 K *Long Term Care Claims Experience Data for Genworth Life Insurance Company and affiliates – December 1974 through December 31, 2011 LTC Claims Experience Data – Company Confidential 15
Overview The Agent’s Role • Help us get Information ü Client Profile Challenges, Special Needs Observations ü Claim Form Follow-up Facility Statements Attending Physicians Statements ü Changes to Care Needs Hospital Stays Increasing Disability
Overview The Agent’s Role • Prepare Client ü Review Benefits – answer specific questions by calling the Claims department ü Keep Current Durable, Health Care/Medical POA Third-party Notification Information • Help with Claim ü Start a Claim 1 -800 -876 -4582 ü Help with Caregiver Records Payment Records Care notes and Invoices
Overview The Agent’s Role • Be Sure to Avoid…. ü Detrimental Reliance “I’m sure you are benefit eligible” “I’ll fix this, don’t worry” ü Adding complexity Agent of Record only Leave time and number for call backs • Understand HIPAA ü Yes Claim Status, Outstanding Requirements, Next Steps ü No Medical Information, Financial Information
Questions and Answers
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