LTC Insurance Claims Process with Dwight Smith

There are many strategies to filing a successful Long-Term Care Insurance claim.

I chatted with Dwight Smith, the owner of AMADA Senior Care Columbus & Toledo, about the LTC insurance claims process.

In this episode we covered:

🔹 Importance of understanding the policy coverage
 
🔹 Exploring additional benefits included (e.g., medical equipment, home modifications)

🔹 Understanding different activation protocols for different insurance companies

🔹 Activities of daily living (ADLs) and cognitive impairments as qualifying criteria

🔹 Need for care for more than 90 days and fulfilling the elimination period 

🔹 Making sure benefits are properly utilized and extended if necessary 

🔹 Doctors documenting the client's needs clearly and specifically

🔹 Encouraging open and honest conversations with physicians 

🔹 The process of submitting a claim 

🔹 Receiving benefits once the elimination period is met

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Watch this episode on YouTube:  https://youtu.be/z9PBfT_1slk

Steadfast Care Planning podcast is made possible by Steadfast Insurance, CLTC, and AMADA Senior Care Columbus.

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For additional information about Kelly, check her out on Linkedin or www.SteadfastAgents.com.

To explore your options for long-term care insurance, click here.

Steadfast Care Planning podcast is made possible by AMADA Senior Care and Steadfast Insurance LLC.

Come back next time for more helpful guidance!

Transcript

Kelly Augspurger: Hey everyone, welcome to Steadfast Care Planning, where we plan for care to live well. I'm your guide, Kelly Augspurger. With me today is Dwight Smith. Dwight is the owner of AMADA Senior Care in Columbus and Toledo. Dwight, thanks so much for being here!

Dwight Smith: Thanks for having me, Kelly. I really appreciate the opportunity.

Kelly Augspurger: Today we are going to be talking about the long term care insurance claims process and what that looks like and because Dwight is an owner of a home care agency, AMADA Senior Care, he has a lot of great insights and experience that he's going to share with us today. So, Dwight, can we jump right in?

Let's do it.

Alright. Well, number one, Dwight, before even submitting a claim for long term care insurance, what are some best practices? What are things that people really need to think about and do?

Dwight Smith: Sure that’s a really good question. So there's a series of things that people really need to do. They need to identify what kind of level of care that they need, what the policy covers, and what that policy covers could be an accumulation of various things. What's the period of the coverage? How much does it cover per day? Maybe it's broken down per month or per year. What the maximum benefit is, maybe the benefit may last a total of four years, two years, or even sometimes, if they're lucky, a lifetime. And then really kind of digging into the weeds to uncover what might be included with that. So there may be some assistance with durable medical equipment. There might be some assistance with home modifications, there might be some assistance with these little hidden gems that we call them and to really figure that out, to see and make a plan accordingly on what kind of things that will be needed as this care persists and then what's needed to activate it, right? So different companies have different protocols. Some require doctor's notes or documentation, some require an assessment via nurse and then having the claim, form and claim packet to fill out to make sure that they have all the proper information so that the reimbursements are on time and in for the amount that they would need or want.

Kelly Augspurger: So really understanding what your contract says, right, what coverage you have, whether it's per day, per month, how long your benefits last, if it's comprehensive and today's policies, most are comprehensive, meaning you can receive care in your home, in a community. It's not a location. It's really a matter of what's best for you. Where do you want to receive care that's going to be best for you? But I think Dwight and you probably run into this most policies, at least policies today are qualified, meaning these qualified long term care policies are going to have specific contract language where it's very standardized. And that means in order to receive benefits, you have to have triggers. And these triggers are either physical or cognitive, right? So it's going to be either two out of six activities of daily living or you need supervision due to a cognitive impairment. And so those are pretty standardized in most contracts today. And then your expected a need of care is more than 90 days and you fulfill an elimination period. So we know that typically is the contract language, but you've got to be aware of what your contract says and if you don't understand it, if you're the client yourself receiving care, you're probably not in the frame of mind to really read it right and understand it. So you're going to have to have a family member look at that contract and policy, but then be able to use a professional like yourself, Dwight, in a service to be able to read that and understand what it says and how you can actually receive benefits, right?

Dwight Smith: Yeah, I agree. I mean, there's the opportunity, you know, sometimes in those benefits to even extend them out. So if it's a two year max and you don't need to meet the criteria of what that monthly max is, then maybe I wouldn't say strung out, but just not fully utilized upfront.

Kelly Augspurger: That's right because most policies, at least today are issued in a factor of it's really a benefit pool. So if you're not using that full monthly benefit, those benefits can actually last longer and they stay inside the policy.
Dwight, let's talk about, I think something else really important to consider before filing a claim is the importance of doctors actually noting in the medical records what is going on with the client. We want to make sure that before submitting a claim, the care that you need is well documented because most carriers are going to look at those medical records just to verify that indeed you do need care and what that looks like, because if it's not documented well and it's gray, they may not approve a claim. So we want it to be very clear, black and white. You know, this is exactly what you or your family member needs help with. You need help bathing because it's unsafe. You don't have good balance. You need help transferring. You don't have the strength or the mobility and so I think it's really important that that's communicated with the doctor before submitting a claim because we want that claim to be approved right away, right?

Dwight Smith: Agreed. Yeah, absolutely.

Kelly Augspurger: Do you see that happen with your clients, Dwight, that sometimes, maybe a claim is not getting approved quickly because we don't have the right documentation?

Dwight Smith: Yeah sometimes it becomes, you know, a situation where the person may not feel like they need it yet. That's where we run into the biggest hurdles is, you know, they say I need a shower, but I don't think I do. That type of thing and we have to go through that or, you know, the pride of needing some assistance. People want to be able to get around on their own, but they are relying on this policy that they've paid in for for the past five, ten, fifteen, sometimes twenty years, and they could use that as a resource and a benefit to continue their life in a healthy and safe way, but sometimes there's a little resistance. Yeah, being open and honest with the physician at the start is the best. Yeah.

Kelly Augspurger: Oh spot on and I've heard this and I've seen this where clients, they just want to be bold and brave. You know? “Oh, no, I'm fine. I don't need help. I can do this on my own.” You're really just jeopardizing yourself. You know, you do. If you have these benefits and you really do need help, you need assistance. Well, guess what? You have benefits that can actually help. The insurance company will pay you. they will pay your family. So this is not the time to be bold and brave and just, “no I'm good. I can do this on my own,” you know? And this is where I think family needs to come into play, too. Dwight, right? So whether it's the spouse or adult kids and they need to talk to the physician and be like, “No mom or dad, this is really what's going on. Let's be honest here. You do actually need more assistance than you think. So let's tell the doctor what's really going on so that you can get the help that you really need.”

Dwight Smith: Right.

Kelly Augspurger: Yeah. Agreed. And now for a brief message from our show sponsor, The Steadfast Care Planning podcast is sponsored by AMADA Senior Care Columbus. AMADA is your one stop shop for in-home caregivers, senior housing advice and long term care insurance claim assistance. Visit AMADASeniorCare.com/columbus-senior-care to learn more.

Well Dwight tell us what's the process once we know that we've got medical records that are documenting actually what's going on, what's the process, how do you help when it's time to actually submit that claim? And I know this can kind of vary depending on the insurance company because claim paperwork can be different, but in general, what is that process like?

Dwight Smith: So typically there's a form that needs to be filled out by both parties and depending on if the client themselves are going to be getting the reimbursement or if we take on the assigned beneficiary, that would determine the form. But they're collecting our insurance information, our tax identification, and then that's submitted. So depending on the policy, there may be an elimination period and during that elimination period, it's very important for us to be able to record or for the client to record the care notes so that there's documentation of when that care started, so that when that elimination period is met, the benefit can start being received.

Kelly Augspurger: Right and I think let's back up even a second and explain what that elimination period is. So in these contracts, there's going to be what's called an elimination period. This is the waiting period, right? The amount of time that the client is self-funding their care before benefits begin. But they're actually receiving care in this time. So every contract is going to have some type of a waiting period. Maybe it's zero days, maybe it's 90 days, 60, 30. You know, it's really going to depend on what that contract says, but that lingo is important to understand and how that actually works. So thanks for talking about what that looks like during the elimination period.

Dwight Smith: Sure. Yeah. So there's even like a part of that that can be included and that's what we need to figure out and we'll ask the families about inquire is “okay, was there any skilled stay?“ because skilled stay sometimes in a rehab even is accounted into that elimination period so they're staying in there for 30 days or you know and they have a 30 day elimination period that might be met. So as soon as they are discharged, come home, the benefit could be applied immediately.

Kelly Augspurger: Right and when you say skilled stay, you're really referring to maybe they're in rehab, right? Maybe getting some physical therapy, OT, just depending on what their needs are that that could count possibly towards that elimination period. So knowing and asking these questions is something that you do in that process to be able to figure out, “okay, where are we at in this timetable? How much time do we have remaining before benefits begin?” Now, just a few minutes ago, too, Dwight, you talked about assignment of benefits and we just kind of skimmed over that really quickly, but I think that's really important specifically when we're talking about reimbursement. So really, there's two main types of ways that people can receive benefits. Reimbursement or cash indemnity and reimbursement is what most policies are today, which is you pay for your care costs and then you're reimbursed by the insurance company. Or if it's cash indemnity, the insurance company is just going to send you a check for whatever that daily or monthly benefit is, regardless of care expenses. So what Dwight was talking about as far as an assignment of benefits goes, is that, you might have the opportunity for the home care agency or even facility if you're in a community to be able to sign a piece of paper that says, you know what, I give authority and permission to this agency or facility to be able to do this on my behalf, right Dwight? Can you talk a little bit about that in more detail?

Dwight Smith: Sure, so there's two parts to that, like what you were saying, Kelly, where actually there's three parts, right? You get the cash or you could get the reimbursement, and that reimbursement can either go to the client or it can go to the company that's caring for the facility that they're in. So how that works is the claim process can be kind of challenging sometimes with submitting claims and care notes and getting those to match up. So the benefit that we offer with AMADA is we'll take on that burden for you and we'll file the claim, we'll file for the reimbursement and we'll take care of the care all in one so that it can really takes out kind of all the legwork and all the frustrations. When we submit something and then they submit something and the insurance company is saying neither party submitted anything and it can add delay to reimbursement. And when a family's really counting on that to be able to keep their finances in order, we want to make sure that there's the least amount of delay there as possible. So we become the advocates at that.

Kelly Augspurger: An advocate and that's exactly what you are and that's what people need during this claims process and just during time of care. You want someone there to be able to advocate for your loved one, especially if you have family all across the country. If you are on claim and maybe your spouse is not able to do this because it's just there's so much detail that it's hard for them to really keep up with it. Or your adult kids, if you have adult kids, maybe they don't live nearby and it's just not feasible for them to do this for you. So having an advocate, somebody like you, to be able to come alongside and say, “you know what, don't worry about this. We've got it. We're going to take this off your plate. We just need you to sign some paperwork giving us that authority and permission to do it on your behalf and we'll take it. We'll take care of it.”

Dwight Smith: Yeah, and I think some families are a little concerned about, okay, if I sign all this over, does that mean. And that could change at any moment. They still hold the key and you know the power to all of this. So if they wanted to change that at any point in time, they could really easily.

Kelly Augspurger: What do you typically see as far as a timeline once you submit that claim, how long does that process typically take?

Dwight Smith: Well, you know, it all kind of depends on insurance company. You know, some of them are pretty quick within a week or so and then some of them it takes a little bit longer. But I would say the average is for them to give us the green light, with the better companies it’s around three days.

Kelly Augspurger: Oh, wow, okay. Once everything's actually submitted, right, like you've got your ducks in a row, all the paperwork is done for them to actually review it. You're saying just a few days. Now what about medical records? Because oftentimes they need to order these medical records. So are you saying after they've even received those medical records from the doctor, it's going to maybe be about a few days for them to review it?

Dwight Smith: Correct, yeah typically it does.

Kelly Augspurger: Yeah. Okay.

Dwight Smith: And sometimes or if it's not a medical record request, they'll have a nurse call in to do an assessment via over the phone. And that could be anywhere from a couple of days to a couple weeks, depending on when that person is available.

Kelly Augspurger: Right, right. The availability amd do you see even nurse assessments in person as well?

Dwight Smith: We do and we offer those to the insurance companies as well, where we have a nurse go in and do the assessment and fill out their form and then submit that for the insurance.

Kelly Augspurger: So sometimes they'll allow that or other times they want to send their own nurse.

Dwight Smith: Correct, yeah. If they have one in the area or whoever they're partnering with.

Kelly Augspurger: And now for a brief message from our show sponsor. The Steadfast Care Planning podcast is sponsored by the CLTC Certified in Long Term Care Training Program, which gives financial advisors tools to discuss extended care planning with their clients. Look for the CLTC designation when choosing an advisor.

What do you see the biggest mistakes in this claims process that people make?

Dwight Smith: I think the biggest mistake that I see is just not having a really good idea of what your policy is and how to activate it. Meaning, for example, maybe there's a little bit of cognitive impairment with someone, but they are activating their policy for a hip replacement recovery. And when they're being asked about their memory, they're being honest, right? But that's not what the care is for. The care is for us to be able to be there, to help them, to get meals and to get up and to exercise. So we just have to really be careful about when we're activating a policy, what we're truly activating it for, especially if there's any type of hidden gem, like a restoration of benefit where we might be in there for a temporary piece of time and the goal is for them to graduate from our care. We want to make sure that that policy is utilized properly.

Kelly Augspurger: The hidden gems. I love that you call them that and what I generally refer to them as other benefits. So these are going to be, you know, home modifications, caregiver training, respite care, care coordination, but you call them hidden gems. I love that. I think I'm going to start calling them hidden gems now because it's true. When you have a policy, you're getting paid, right? You've got this monthly income coming in to pay for care, but oftentimes you have these wonderful hidden gems in the policy that you may not know you have but that are really beneficial.

Dwight Smith: Yeah. So we want to make sure that we just have a clear understanding of all those so that when we're activating it, we're not making any mistakes. Yeah.

Kelly Augspurger: Yeah. Now I know that you help in the process as far as initiating the claim. What about, you know, typically, maybe once a year the insurance company might need to come back to you and ask some additional questions. What does that look like? Do you help in that process? If you're helping a client that has a policy?

Dwight Smith: Yeah, we do. We do. You know, we keep clear records on our end and we have documentations in the system. So if they call at any point in time and we do get challenged on that, sometimes reimbursements get a little wonky and we'll get three weeks straight and then there will be a week that's skipped. And then we have to go back and really dig into the weeds and figure out why that reimbursement hadn't come in and be able to clarify why that was inaccurate, but we do keep records very, very tight so that if the insurance company wants to come back and question at any point in time throughout that level of care or that time of care, the period of care,that we would be able to respond appropriately.

Kelly Augspurger: So detailed notes, so important.

Dwight Smith: Yeah.

Kelly Augspurger: I mean, that's something that your team does really well. And I think even across all the AMADA franchises. It's just something that's kind of innate within your company is that you guys know the importance of taking really good notes, not just for the insurance company, but for the families. And I'm sure even just as like a litigation buffer to protect yourselves as well. We need to make sure that we are documenting exactly what services were provided, even like the timing and just really being able to document that well is really important.

Dwight Smith: It is. You know, when it comes with, you know, our workings with some of the guardians, elder law attorney guardians, too, right? So we become the point of contact to the family, I guess you would say of yeah, hey, so-and-so needs a new pair of pants or shoes or clothes. So those little notes really become important in people's lives.

Kelly Augspurger: That's a great point. Do you guys charge a fee for this, Dwight, or is it something that's just included because you're also providing care?

Dwight Smith: It's all inclusive.

Kelly Augspurger: Okay. That's awesome. So when you bring on a new client, they don't have to worry about, oh we're not going to have to pay an additional fee for these services. But you know, we're paying them to provide care for us and it's just included.

Dwight Smith: Yeah, we're the long term care insurance claims advocates.

Kelly Augspurger: You sure are.

Dwight Smith: It's all wrapped in.

Kelly Augspurger: Yeah and I know you guys are really well known for that and do a really good job with that. Well, Dwight, any final advice on how people can plan for care to live well?

Dwight Smith: Well, I would think just communicate. I'm going through this with my mom right now. She's 84, and we're just constantly communicating to make sure that families and clients do this as well. Things change. So keep it kind of creating a goal, a plan, but reevaluating that and revisiting and rediscussing it constantly, maybe at least quarterly, if not at the very longest yearly, because things change and having a good group of people like you and friends and families, financial advisors, elder law attorney, having a good team involved to make sure that whatever goals are in place, stay the goals that they want them to have.

Kelly Augspurger: I totally agree. Open communication, consistent open communication with your loved ones, especially as they get older because things can change overnight, right? Especially if there's a fall or if there's some type of an incident that happens or a health event, that can really change things quickly. And so you want to be honest and open with your loved ones of what's going on and keep them abreast of the situation so that you can be safe, you know, and get the care that you really need.
Well, Dwight, thanks so much for your time today. Where can people find more information about you and AMADA and how you help people?

Dwight Smith: Sure, a couple of different ways. So www.AmadaColumbus.com our website or you can call our number 614-721-0070 and I’m happy to talk with anyone at any time.

Kelly Augspurger: Awesome. Well, Dwight, thanks so much for your time today. Really appreciate the insights that you've given us. I know the claims process can be overwhelming at times for people, especially if you're not in the industry, right? This is an unknown territory. So to be able to give people some just golden nuggets of tips and information I think is going to be really valuable. So really appreciate your time. Have a great day!

Dwight Smith: Thank you, Kelly. You too. Thank you.