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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 4th – 6th, 2011

Objects in the Rear-View Mirror Not Always as They May Appear

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Underwriting - The Journey

◊ Risk assessment◊ Agents◊ Cycle time◊ Balanced risk pool

◊ Production◊ Declines◊ Requirements

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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◊ 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◊ 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◊ 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

◊ 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◊ 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◊ 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◊ 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◊ 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◊ 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◊ 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◊ 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 screensPharmacy screenMIBStroke risk profileSpecialty records

◊ Evaluate claims with the mirror in mind

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QUESTIONS?