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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. 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.

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Long-Term Care International Forum Albuquerque, New Mexico May 4 th – 6 th , 2011

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  1. Objects in the Rear-View Mirror Not Always as They May Appear LTC Underwriting to ClaimsPam 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

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

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

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

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

  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. 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. 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. 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. 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. 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. QUESTIONS?

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