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Expectation Management

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Expectation Management Powered By Docstoc
					C       EXPECTATION
L       MANAGEMENT
A                     or
I
  “The Times They are a Changing!”
M
S        Session 2: February 27, 2006
              Session Producer:
           Cam Cook, Vice President
            Claims & Underwriting
                 AEGON USA
C       Our Distinguished Panel
L      Represents over 50 Years of
A           LTC Experience
I       Carolyn Eickenberg, Vice President,
M         Complex Issues, AEGON USA
S   Roger Desjardins, Corporate Vice President,
         New York Life Insurance Company

            Renee Roberti-Klemenok,
         Adjudications/Technical Services,
                Genworth Financial
                                                  2
C            Housekeeping:
L
A • The opinions of the panelists are their
I   own. They are not representing the
    policies & beliefs of their employers.
M
  • Please hold your questions and
S
     comments until the Question & Answer
     time at the end of the session.



                                              3
C This panel will address changes
L over the last 5 years in Claim’s
A Departments.
I
M
  Please remember; that what
S
  happens in Claims today, reflects
  what happened in the marketplace
  5-15 years ago.

                                      4
C     Changes in Claimants, Care
L     Providers, Company Goals,
A       Regulatory and Social
I       Environment result in:
M • Changes in how we adjudicate claims
S
   • Changes in customer perceptions
   • Changes in how we communicate with
     claimants and others


                                          5
C
L
    What are some of the
A   changes over the last
I   5-10 years which are
M   dramatically affecting
S
       Claims today?



                             6
C               Characteristics
L
      Topic        80’s & 90’s           2000 on
A
I   Applicants •Late 60’s or 70’s   •Younger
M              •Individual          •Rising group,
                                    worksite & affinity
S
    Policy     •Mostly non-TQ  TQ
    Type on    Med Nec         Comprehensive
    Claim      •Commonly stand (NH, ALF, HC)
               alone NH or HC

                                                      7
                 Characteristics
C
       Topic          80’s & 90’s            2000 on
L
    Providers    •NH & HC                 •Blurring of line
A                •ALF emerging            between NH &
I                through 90’s             ALF
M                •All three services      •Rising Chains
S                clearly differentiated   and Franchise
                                          organizations
                 •Mainly Independent
    Care         •Seldom used             •Blurring care &
    Coordination •Little claimant         insurance
                 contact re: services     •Great contact
                                          with claimants
                                                          8
                   Characteristics
C Topic          80’s & 90’s                2000 on
L Technology    •Primarily phone
                & mail
                                   •E-mail, EFT, Websites,
                                   Fax, Image, etc.
A               •Lower time        •Pressure for faster service
I               service            and better status info
                demands
M Regulatory    •Limited Federal   •Tightening Privacy Regs
S Environment   involvement        (GLB, HIPAA)
                •More freedom      •SOX (segregation of
                dealing with       duties)
                family members     •State licensing complexity
                & care providers   •State mandates overruling
                                   policy provisions
                                   •Rising appeals, DOI,
                                                             9
                                   advocacy, & litigation
                      Characteristics
 C Topic                80’s & 90’s                2000 on
 L
Fraud,               •Believed to be         •Entitlement mentality
 A
Misrepresentation,   limited                 •Shorter POC’s
Overpayment,         •More limited           •More Reassessments
 I
Service Changes      opportunity             •More fraud
 M
(reassessment)       •Few anti-fraud         •More service changes
                     activities
 S                                           •More overpayment

Rehab                •Very limited due to    •Great claimant
                     a) benefit structures   opportunity
                     b) Highly debilitated   •More benefits to
                     claimants,              support it
                     c) limited rehab        •Greater vendor
                     resources               capability          10
C
L      As you can see,
A   “The Times They Have
I      Been Changing”
M
S




                           11
C   Now we will talk about how
L   some of these changes are
A         resulting in:
I
M   •Changes in Claims Activities
S
    •Changes in Communication
    to manage expectations

                                    12
C
L
A    Care Provider Change
I
M           “ALF’s and
S
    Nursing Home Only Policies”



                                  13
C ALFs in late 80’s to late 90’s
L
A • Clearly differentiated from NH
I • Focused on younger, independent
M clients
S • Avoided people with dementia or
    requiring Nursing Care
  • Limited knowledge of LTCI
  • Limited involvement in Claims

                                      14
     ALF Changes from Late 90’s
C
            to Present:
L
A • Blurring of line between ALF & NH
I • Emergence of specialty ALF’s such as
M Alzheimer's Care
S • Increased Nursing Capability
   • Increased knowledge of LTCI
   • Increased advocacy/marketing role in
     “helping” claimants get benefits

                                            15
C      The NH / ALF Problem(s)
L
A • Many claimants with NH Only Policies
I • Claimant and ALF focus on “care wants”
M rather than policy benefits
S • Emotional & Financial commitment of
     claimant and family to ALF of choice
   • Complexity and frequently changing
     state regulation and licensing

                                             16
           The NH / ALF Problem(s)
C
L • Many ALF’s have evolved to sales /
    advocacy organizations to attract LTC
A   policyholder clients
I • Process may include:
M    – Encouragement of facility placement prior to benefit
S      approval
        – Implicit assurance of benefit approval
        – Persistent attempts to “overcome objections” to
          facility approval
     • Denials, frequent use of appeals and DOI
       complaints
                                                            17
  Process & Communications Change to
C   Manage Expectations and Mitigate
L         Complaint Problems
A   • Disciplined adherence to policy provisions
I   • Establishment of specialty staff with in depth
      knowledge of policy criteria, state insurance
M     and facility regulation as well as ALF activities
S   • Discussion of Claims Process at time of first
      claim contact
    • New claim correspondence which includes
      notice of facility evaluation process


                                                      18
    Process and Communications cont…
C
L   • Immediate provision of a list of covered
      Nursing Homes for claimant to consider in
A     case their facility of 1st choice is not covered
I   • Frequent status letters on Facility Evaluation
M     Process
S   • Currently developing new Claims Brochure
      which includes facility evaluation
    • Currently designing new Facility Evaluation
      tool matched to our policies and special state
      requirements.

                                                         19
C
L   MANAGING EXPECTATIONS
A
I                  Renee Roberti-Klemenok
M                     Adjudication Leader

S                     Genworth Financial


     Society of Actuaries Sixth Annual Intercompany LTCI Conference
                          Anaheim, California
                           February 26, 2006
    Genworth – Use & Influence of New Technology

C
       CUSTOMER                    PRODUCTIVITY &             CONTROLLERSHIP &
        SERVICE                      WORKFLOW                 RISK MANAGEMENT


L    Digitized Notice of        100% Paperless Workflow     Electronic Q/A Tool;

A    Claims Tool at Intake
     EFT: Direct Deposit
                                Single-System; All-In-One
                                Portal for Claims Admin.
                                                            Built-In Sampling &
                                                            Workflow Logic


I    “Payment Cycle Date”
     For Predictability
                                Electronic Data
                                Interchange With Vendors
                                                            Suspect Claims Engine
                                                            Waiver of Premium

M
                                                            Engine (Implementation
     Call Evaluation Software   Payment Engine – Pattern
                                                            Q2 ‘06)
     For Consistent Service     Recognition Technology

S
                                                            Automated Checks &
     Real-Time Information      Claim Assignment Based
                                                            Balances To Minimize &
                                On Product, State, Risk
     On The Horizon:                                        Eliminate Errors
                                Segment
      - Phone-Based Invoice                                 Reconciliation Reports
        Submission              e-Workflow To Vendors
                                For Data Entry Tasks        Automated “Risk
      - Web-Based Invoice                                   Segmentation” –
        Submission              One-Touch Printing &
                                                            Continuous Care Claims
                                Mailing of Letters
      - Phone & Web
        Statement of Services   Automated Benefit
                                Calculations
    Genworth – Suspect Claims Process & Technology
            GROWING                   OUR OBSERVATION                        OUR ACTIONS

C           CONCERN                   OF TYPICAL CASES



L      Fraud Is A Growing           Typical Insured:                      Process
       Concern                       - Under Age 62
                                                                           - Robust Anti-fraud


A
                                     - Subjective, Recoverable, or           Guidelines
       Beginning Traces In LTC         Vague Medical History
       Industry                      - Insured/family With                 - Weekly Drop-in Sessions
                                       Medical/Legal/Insurance               To Review Suspect

I
       Clear Need To                   Backgrounds                           Cases
       Proactively Address           - Familiar w/ insurance process-is
                                       receiving Workers Comp/DI           - Suspect Cases


M
                                                                             Transferred to “Suspect
        Nearly One in Four U.S.     Typical Policy :                         Claims Specialists”
     Adults Say That Overstating     - Unlimited/lifetime Benefits
                                                                          People

S
         the Value of Claims to      - High Daily Max Benefits
       Insurance Companies Is        - Max Benefits Claimed for Each       - 2 Suspect Claim
      Acceptable, and More Than        Month                                 Specialists
    One in 10 Say They Approve of    - Claim Filed During Contestable
     Submitting Insurance Claims       Period                              - Adjudicators’ Heightened
     for Items That Were Not Lost    - CA, FL, NY                            Awareness Of Anti-Fraud
    or Damaged or for Treatments                                             Guidelines & Outcomes
       That Were Not Provided.      Typical Caregiver:                       of Investigations
                                     - Caregiver Works 24/7 or Directly
                                       Per POC                            Technology
                                     - High Dollar Hourly Rate             - Rules-based Suspect
                                     - Undisclosed Family                    Claims Engine
                                       member/Domestic Partner/Friend
C          PRIVACY
L
A   Managing our Customers through
         HIPAA Compliance…
I
M
S         Carolyn Eickenberg, VP
    Complex Issues – Claims Department
    Transamerica Life Insurance Company
          Long Term Care Division
C Satisfying Today’s Customers
L           Post HIPAA
A
           April 15, 2003
I
M
S

                 HIPAA
                                 24
C        HIPAA Refresher
L
A   I keep hearing about it, but remind me
I   one more time,
M
S    What is Minimum Necessary?



                                             25
C Minimum Necessary Rule
L
A It is the policy of the Company, that
I  all uses, disclosures, and requests
M for PHI shall be limited to that which
S       is reasonably necessary to
  accomplish the intended purpose of
      the use, disclosure, or request.


                                           26
    Customer Expectation prior to
C
          April 14, 2003
L
A
I
M
S

    •More open communications with all depts.
    •Informal style


                                                27
     What was the Immediate Post
C
          HIPAA Response?
L
A • Angry Customers
I • Defensive Providers/Doctors
M
S




                                   28
  What we have done to manage our
C
      Customer Expectations…
L
A • Pre-claim to all policyholders:
I   – Annual HIPAA Mailer
    – Annual Newsletter
M   – Claims Brochure (to come)
S • At Claim; Provider Claim Packet with
     filing instructions and HIPAA forms:
      – Family and Friends Release Form
      – Medical Records Release Form
      – Attorney Release Form and POA

                                            29
  What we have done to manage our
C     Customer Expectations…
L
A • Telephone Discussion of HIPAA
I   requirements at 1st notification of
M   Claim by Intake Specialist.
S • Status Letters requesting HIPAA
      Forms
    • Provider/Doctor Letter explaining
      HIPAA


                                          30
    Family & Friends Release Form
C
L
A
I
M
S




                                    31
C
L
A
I
M
S




    32
    Attorney Release of Information Form
C   AUTHORIZATION FOR RELEASE OF INFORMATION TO ASSIST WITH ADMINISTRATION /
    HANDLING OF A POLICY

L                A COPY OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL
    I hereby authorize the use and/or disclosure of my personal information as described below:

A   1) (co) may use and/or disclose my personal information to assist me in the administration/
        handling of my policy.

I
    2) Person(s) authorized to disclose: (co), its representatives, reinsurers and business
        associates.
    3) Person(s) to whom disclosure will be made: (att), and associated staff

M   4) Description of the information that may be used or disclosed:
        The protected health information necessary to fulfill the request of the person described in
        section 3 above. This may include, policy number, address, telephone number, gender, date

S       of birth, financial and health information, including but not limited to payment history, claims
        history, policy benefits, and all applicable policy and application details.
    5) The information will be used or disclosed only for the following purpose(s):
         to assist with the claim filed under Policy (no)
    STATEMENTS OF UNDERSTANDING & ACKNOWLEDGMENT:
    •   I understand that I may refuse to sign this authorization, and my refusal will not affect my
        eligibility for benefits under any particular insurance policy.
    •   I understand that any information disclosed pursuant to this authorization may be redisclosed
        and not covered by federal rules governing privacy and confidentiality of health information.
    •   I understand that I may revoke this authorization in writing at any time, except to the extent
        that action has been taken in reliance on this authorization, by sending a written revocation to
        (co), P.O. Box 93019, Hurst, TX 76053. I understand that I am entitled to receive a copy of
        this signed authorization.
    •   This authorization will expire 24 months from the date signed.
                                                                                                       33
                       HIPAA Provider Letter
C   We are in receipt of your letter dated **, in which you request that we provide your organization

L
    with an authorization for the release of medical records because of the Standards for Privacy of
    Individually Identifiable Health Information (the “Privacy Rule”) promulgated in connection with the
    Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

A   Pursuant to the Privacy Rule’s definitions, **<provider name> is a “health care provider,” and the
    Long-Term Care Division of **<our Company name> is a “health plan.” 45 C.F.R. § 160.103.

I
    Therefore, both entities are considered “covered entities” under HIPAA. 45 C.F.R. § 160.103.
    Accordingly, the sharing of Protected Health Information (“PHI”) necessary to facilitate payment,
    treatment, or operations is permitted by the Privacy Rule without an authorization. 45 C.F.R. §
M   164.506. The Health and Human Services Department further explained this position in a
    document entitled “OCR Summary of the HIPAA Privacy Rule – April 11, 2003,” which can be

S
    found at www.hhs.gov/ocr/hipaa/privacy.html. The applicable explanatory language appears on
    Pages 4 and 5 of the document in the section titled “Permitted Uses and Disclosures” under (2)
    Treatment, Payment, Healthcare Operation.” **<our Company name>** would be happy to
    provide a copy of the document to you.
    Since the medical information requested from **<our Company name>** is needed for “payment”
    activities as described by the Privacy Rule, it is not necessary for **<our Company name> to
    provide you with an authorization for the release of the requested medical records. 45 C.F.R. §
    164.501; 164.506(c)(1) & (3). For your convenience, we have enclosed a copy of our previous
    correspondence which reflects the information needed.

    If you have any questions about this before providing the requested information, please let us know.
    We can be reached toll free at (866) 745-35**.

                                                                                                         34
C
L
  What we have already done……
A
I • Online System Window that houses all
    PHI information.
M
S




                                       35
C
L
A
I
M
S




    36
C          Continuing to protect our
                Customer’s PHI
L   What is the Objective for 2006?
A   • Establish ownership and span of control as it relates
      to Minimum Necessary and control access of PHI by
I     employees.

M   Role Profile Templates (HIPAA & SOX / Computer
      Access
S   • Create Role Profile ID’s for every Job/Role
    • Map Role Profiles to specific job titles;
    • Revise Job Descriptions to include Role Profile ID’s
      and
    • Update Job Descriptions with Span of Control
      Language as it relates to PHI.

                                                             37
C          What is our Goal?
L
A • To further drill down the job descriptions
I   to a specific Role Profile and determine
    if the Role Profile does or does not have
M access to PHI.
S




                                                 38
C    Job Descriptions – Phase I
L   Revise Job Descriptions to include Role Profile ID’s
A
I
M
S
                                                       Role
                                                     Profile ID
                                                     Addition




                                                           39
    Job Descriptions – Phase I
C Update Job Descriptions with Span of Control Language
L    for those who do access PHI.

A
I
M
S
                                               Example of
                                                Language
                                               Addition for
                                               EE’s who do
                                               Access PHI.


                                                          40
    Job Descriptions – Phase I
C    Update Job Descriptions with Span of Control
     Language for those who do not access PHI.
L
A
I
M                                                   Example of
                                                     Language
S                                                   Addition for
                                                     EE’s who
                                                      do not
                                                    Access PHI.




                                                           41
C        Avoiding / Limiting
L
A • Fraud/Misrepresentation
I • Overpayments
M • Misunderstandings
S
            In Facility Claims



                                 42
    Managing Claims and Claimant’s Expectations
    for Nursing Home and Custodial Care Facility
C   placement…
L       • Early 1990 Placement
A        – Policy Eligibility – Medical Necessity
I           • Lifetime Benefits
         – Permanent Placement
M           • Dementia – Alzheimer’s
            • Cerebrovascular Disease
S      • Assessments/Reassessments
         – Update periodically
            • Medical Data Sets
            • Service Plans
       • Clients – Family
         – Honesty
         – Integrity
                                                    43
C
L
            Question:
A
I    Why would you continue to
M   reassess Claimants that are
S permanently placed in a Nursing
   Home or Custodial Care Facility?



                                      44
C
L
A
                Answer:
I   To determine if we are paying
M    benefits to Nursing Home or
S   Custodial Care Facility clients
      who are no longer residing
             in the facility.

                                      45
                        Pilot Project
C       Verify through a vendor by an unannounced visit that
        the client is alive and well and residing at the
L       location for which benefit payments are being made.
A   • Identify 200 insureds with the oldest incurred dates
I     with placement for Medical Necessity
    • Identify 200 claimants by name band or nurse
M     identity
S   • Identify type of facility
                           Outcome
    •   195 Claimants were where they were suppose to be
    •   2 Were recently deceased
    •   2 had moved to another facility
    •   1 Fraud case was detected

                                                             46
C   The Case of…
L   The Missing Facility!
A
I
M
S




                            47
C
L
A
I
M   What Happened?
S




                     48
     Managing Claims and Claimant’s
C   Expectations in the Current World…
L
A   Best Claim Practice: All claimants will be assessed
      on site at least once a year regardless of eligibility
I    requirements in an effort to ensure that we pay only
                  those benefits which are due.
M
S   • Introductory Correspondence
    • Care Coordination Offer to All Claimants
    • Intake Specialists proactively calling all
      Claimants explaining POC and
      reassessments

                                                          49
       Managing Claims and Claimant’s
C     Expectations in the Current World…
L
A •   Initial Independent Assessments
I     – Onsite ADL’s – IADL’s – Cognitive Tests
      – Notice of Reassessment dates
M•    Independent - Reassessments
S     –   Onsite Reassessments
      –   Plans of Care with reassessment dates
      –   Medical Records
      –   Facility - Provider Service Plans
      –   Bed Licensure
  •
                                                  50
C   Managing (ever-changing)
L       Expectations
A
I
M      Roger E. Desjardins ALHC
           Corporate Vice President
S        Policyholder & Claims Services
      New York Life Insurance Company
C        Growth → Attention → Expectations
L •   Portfolio growth/product development = highly technical
A     environments - lots to track, administer and ‘get-right’;

I •   Policyholder base expansion = more demand on
M     infrastructure and support services;

S•    Maturing blocks of business = more claims on older
      products – the world changed but the “rules” didn’t!

  • Claimant-becomes-customer = “….you thought what,
    Mrs. Smith?….” ;


                                                              52
C            Expectations from
L
A   •   Distribution Channels
I   •   Prospective Buyers
M   •   Policyholders
S
    •   Claimants
    •   Management



                                 53
C        Distribution Channels
L • ’80s / ’90s LTC 101
A      • Selling the risk – education on need / UW
I      • Selling the product – education on contract
M      • Selling the “promise” – education on claims

S • ’90s / ’00s Sales Experts
          • ‘Engaged’ Sales Support – technical resource
          • Service Excellence – agent & client
          • Testimonials – “selling claims”



                                                           54
C           Prospective Buyers
L
  ’80s / ’90s -“Welcome to the kitchen table”!
A       • ‘Dropping-in’ for the sale – HELP?
I       • ‘Undoing’ good intentions…
M
S ’90s / ’00s “Welcome to my competitive
     analysis”!
        • Highly informed and savvy consumers
        • Tell me why I should buy company “X” vs. “Y”



                                                         55
C    Policyholder Expectations
L • Early ph expectations minimal:
A      • Premium Billing & collections
I      • Occasional plan change / bio
M      • Few reasons to have follow up contact

S • Today, frequent & important touch points
        •   Mobile – frequent address changes
        •   Adjusting plans and portfolios
        •   Additional required touch points (3rd-party desig.)
        •   Frequent in-bound inquiries


                                                              56
C        Claimant Expectations
L • ’80s / ’90s – ‘low touch’
A      • Infrequent contact with claimant
I      • More likely to be SNF based – more impaired
M      • ‘Simpler’ administration - indemnity models

S • ’90s / ’00s – ‘high touch’
          •   Claimant frequently initiates claim
          •   Opportunities for intervention/partnering
          •   Monthly contact on payment reconciliation
          •   Multiple claim events over several years


                                                          57
C     Customer Defining Expectations
L
A                      • Access
                         – Easy to reach
I                        – Knowledgeable staff
M      “AAA”
                       • Assurance
S   Service Delivery     – “We hear you!”
                         – “What we’ll do next, is….”
                       • Action
                         – Follow up; status
                         – Follow through; feedback

                                                   58
C     Management Expectations
L   • Our ‘Fickle’ Philosophies – what drives your claim
      shop – do you know? If so, have you shared it?
A   • What’s “in” this year? The elusive search for the “ideal”
I     claim model and philosophy….it must be ‘out there’??
    • Be careful what you change and how quickly you
M     change it:
S         • the “chemistry” of a claim shop ‘equilibrium’;
          • everything has a balance,and its easily disrupted;
    • Suffer from analysis-paralysis?
          • GET OVER IT!
          • Do what’s right for YOUR organization
    • Make decisions / experiment / move forward - wisely!


                                                                 59
C
            Management Advice
L   • Pay attention to your Claims Staff – Listen / Observe /
      Monitor / Query – its your ‘early detection center’
A
I   • Invest-in and nurture talent – overloading the
M     “engine” gets you nowhere – fast.

S   • We’re not “there” yet – expect more change, in all
      aspects of your operations

    • Listen to your Customers – the best mirrors of your
      overall performance


                                                           60
C
L   QUESTIONS?
A
I
M
S




                 61

				
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