Why the Long Term Care Claims Gets Stuck

Help long term care claimI was on the phone this week with an 88 year old woman whose 91 year old husband was in the nursing home.  The nursing home said they had filed the long term care claim for her.  They had.  But she was paying her 6th month of nursing home fees and still no indication from the carrier that they had met the 90 day self-pay window.  Thus the call to our office…

So, we 3-way called the long term care insurance carrier to find out what the problem might be.  As so often happens in this process, somewhere along the way not all the bills and documents got thru to the carrier.  My sweet 88 year old lady kept repeating:  but the nursing home said they send it – they have proof they sent it.

And therein lies the sticking point in the process!

Just because the long term care provider sends in the documentation, this doesn’t mean that the fax machine worked correctly on both ends or that the human who pulled the fax on the far end didn’t make an error.  Nor does it mean that when everything works perfectly on document transfer that the person who enters the benefits to cut the check won’t make an error and the claim will pay, but not the right amount.


To insure that the claim pays properly SOMEONE must MANAGE the process – they must make sure the documents are sent in, that the documents are correct before they go in to the carrier, and that all pages of the document arrive at the carrier and in the right file.  Then, when the benefits are awarded that same person must check the Explanation of Benefits (EOB – see our other blogs about reading the EOB) to be sure everything paid correct amounts and refile or appeal anything that is improperly denied.

When I tell people this is the process, they get upset and annoyed.  This isn’t how their OTHER insurance works ….or so they think.  Wrong.  It is just that on your other health insurance the care provider is doing all of this for you.  In this line of insurance, the care provider (nursing home, assisted living, home health care…whatever you are using) is NOT doing all of this for you (for the why of that see our other blog on Assignment of Benefits).

Simply put – the process of long term care claims gets stuck because no one is managing it.  Like every other paper-work intensive activity (filing taxes, selling a home, or medical health insurance), you are either going to do this yourself or hire a professional to do it for you.  If we can help you with managing the process of long term care claim filing, give us a call.  This is what we do.


Some other long term care links to help you.

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