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32 | On 04/09/2024, LPA conducted a complaint investigation visit to the facility above. During this visit, LPA requested and received relevant documentation pertinent to the complaint allegation for record review. LPA additionally interviewed both staff of the facility and residents in care at the facility during the complaint investigation visit. LPA received documents from the facility including an insurance claimant care needs assessment form to be completed by a licensed clinician to process a resident’s long-term care claim, insurance continued monthly residence form required as part of a monthly claim submission, an insurance company facility form regarding a claim for charges covered by the facility, insurance company facility verification form, insurance monthly verification form to be completed each month after services have been rendered, and insurance confinement form providing benefits on behalf of a resident based on residency in the facility. Each insurance form received by LPA from the facility is between 1-2 pages in length and all forms require dates and signatures from facility staff and/or a professionally licensed clinician. Each insurance form has multiple sections and/or questionnaires required to be completed that include resident information, facility information, provider information, and licensing information.
Staff of the facility stated during their interviews with LPA that, beginning 05/01/2024 residents will be charged $150 when they submit forms or paperwork to the facility office to complete insurance paperwork so they can receive services from their long-term care insurance. According to Staff, the facility medical director sees approximately 12-15 residents, while most residents are seen by their own primary care physician (PCP). The census at the time of the initial complaint investigation visit by LPA was 350 residents in the facility. Staff stated to LPA that it takes about 3-4 hours a month to complete paperwork for each resident. Paperwork is usually completed by the residents' own PCP. A long-term care medical technician from the insurance company is first sent to do an assessment of the resident for eligibility and the assessment is then sent to an insurance adjuster for consideration. The services must be re-certified every 6 months to 1 year. The residents receive a monthly invoice for these services. Per Staff, the residents can complete their own insurance paperwork. The facility office completes only, if necessary, sections of the insurance forms such as: Can the resident remain in the same apartment for the entire month, were they hospitalized in the last month 1st - 30th, description of current apartment - Memory Care, Skilled Nursing, Assisted Living, and is any of the amount covered by Medicare or private pay.
Report Continued on LIC9099-C. |