tmk1536 0410agent training only. not for sales use. claims dawn mitchell senior vice president...

TMK1536 0410 Agent training only. Not for sales use.

Claims

Dawn MitchellSenior Vice President

Policy Benefits



Claims

• Policy Benefits Overview• Liberty cancer/critical illness/other health claims statistics• Liberty life claims statistics

• Filing Cancer Claims• What is required for processing

• Filing Life Claims• What is required for processing


Claims

• Life Claim Challenges• Branch Manager/Agent Involvement in Claim

• What you should and shouldn’t do• How you can assist the claimant

• Procedure for Claims Inquiries


Liberty Cancer/Critical Illness/Other Health Claims

• 700 - 750 claims processed/week Liberty Cancer claims are the most difficult of all

claims to process• $1+ million paid on a weekly basis for Liberty

cancer/critical illness/other health claims• 9 examiners dedicated to paying these claims


Turnaround time for Liberty Cancer/Critical Illness/Other Health Claims

• 2007 turnaround – 13.9 calendar days

• 2008 turnaround – 8.3 calendar days

• 2009 turnaround - 7.5 calendar days


Liberty Life Claims

• 700 Liberty life claims processed/week• $3.5+ million paid/week for Liberty life claims• In Q1 2010, 99% of Liberty life claims received were

incontestable and only 1% were contestable• 7 examiners process incontestable life claims • 9 examiners process contestable life claims • 2 medical reviewers read and summarize medical

records


Turnaround Time for Liberty Life Claims

• Turnaround time for Life includes both contestable and incontestable claims

• 2007 – 11.5 calendar days




Filing Liberty Cancer Claims

• For initial claim, need Claimant Statement (claim form L-252)



• In addition, we require the Claimant Statement to be submitted annually (do not submit with each claim)

• For initial claim, need pathology report showing a malignant diagnosis



• Most common types of bills submitted for cancer claims• UB04 (standardized billing form used by hospitals)• 1500 (standardized billing form used by Dr. offices)• Itemized bills showing the service date, type of service

rendered, charge per service, number of units per service, and the diagnosis

• Pharmacy receipts of the drug providing the date, type of drug, NDC number (prescription number), and the actual drug costs



Example: Insured had inpatient hospital stay and cancer treatment was given

We need the UB04 which shows the diagnosis codes so we can verify that the confinement related to the treatment of cancer

From the UB04, we can pay room and board benefits that are owed



We can not pay radiation/chemotherapy benefits from the UB04 because it will only list one summary charge for “drugs/pharmacy”

In this instance, the itemized bill with the CPT/HCPCS codes (procedure codes) are needed with a day by day breakdown of the charges so we can determine which drugs are payable under the terms of the policy (i.e. which drugs were given for the treatment of cancer)



In this example, the examiner will pay the room/board benefits and send the insured a letter explaining that additional benefits may be due if the insured can submit the itemized bill


Filing Liberty Life Claims

• Incontestable life claim – date of death occurred more than 2 years after issue date of policy

Need death certificate or funeral director’s statemento Funeral director’s statement is accepted in lieu of

death certificate if face amount is $10,000 or lesso A copy of the death certificate is accepted if face

amount of policy is $10,000 or lesso If face is more than $10,000, a certified copy of

the death certificate is required



Death certificate must include the cause and manner of death; we’re trying to determine if death was due to homicide (additional documentation may be required for homicide)

Obituary (we ask for this although it is not required – we will still pay benefits without it); obituary can be very helpful to Claims if we are having difficulty locating family members or determining beneficiaries

Documentation from beneficiary with his name/address (most beneficiaries utilize the Liberty life claim form R-425 although this is not a requirement to file an incontestable life claim)



• Contestable life claim – date of death occurred within 2 years after issue date of policy

Death certificate and obituary requirements are the same as for an incontestable claim

Require the claim form to be completed – this contains the HIPAA authorization which we need to be able to order medical records from providers; also contains the physician’s statement



Other documents that we may request in our investigation include: coroner’s report/autopsy, police report, toxicology report

Investigating a contestable claim can be a lengthy process since we are dependent upon providers and other 3rd parties to give us the information we requested


Liberty Life Claim Challenges

Many times a doctor or hospital will not accept our HIPAA authorization and will require us to use their “special” authorization

This causes us to have to go back to the family for another signature

Provider sometimes requires estate paperwork before they will release medical records

Some providers are very picky as to who can sign the HIPAA authorization (next of kin)


Liberty Life Claim Challenges

Claims procedures are explained in the Agent Instruction Guide (Form 59)


Life Claim Challenges

• Beneficiary is deceased; benefit would be paid to “estate of” deceased or beneficiary depending upon who died first


Life Claim Challenges

Benefit payments is due to “estate” but there is no estate that was establishedo If benefits are $10,000 or less, can use release

and indemnity agreemento If benefits are more than $10,000, family will need

to get a small estate affidavit from the court


Life Claims Challenges

Beneficiary is a minor Beneficiary is a spouse but now is divorced from the

insuredo If a “divorce” state, we need the divorce decree in

order to determine who receives benefits


Branch Manager/Agent Involvement in Claim – What you should and should not do

• Agent should not express an opinion on whether or not a claim will be paid

Agent should indicate that benefits will be paid according to the policy provisions

• Agent should not indicate to whom a claim payment will be made

There could be an assignment or other situation of which the Agent is not aware



• Agent should not guarantee when claim payment will be made

Agent should set expectations when a contestable claim is involved; processing time is increased due to conducting a claims investigation.



Majority of investigations are complete within 90 days but can take longer if we don’t get cooperation from provider/facility or if insured/beneficiary does not return information requested from Claims Dept



• Agent should not promise a claim payment to be sent “overnight” to an insured

Claim payments sent “overnight” occur infrequently and are only sent in unusual circumstances

Once a claim is processed, the claim check is not generated until the following day; once generated (at our printing facility in OKC) the check will not be released for a couple of days (printing facility must go through their audit and balancing process)



Pulling a claim check to be sent overnight is a manual process and involves several individuals

Manual processes are dangerous – we are relying on each individual to perform tasks that are outside of the normal process



• Agent and claimant should allow adequate time for an insured/beneficiary to receive a check before requesting reissue of a check

Claim Department policy is to not reissue a check for 30 days (exception exists if the check was sent to an incorrect address)



Mail date can be affected by several factors: o Dollar amount of claim (claims over certain amount

require extra review by Claims management)o System issues which prevent check from being

generated when it shouldo Balancing and audit process which must take place

at OKC printing facilityo Slow postal service

Putting a “stop pay” on a check is costly to the Company (typically $35) and usually unnecessary



We have many instances where we issue a replacement check and then the claimant receives the first check and tries to cash

If we placed a stop payment on a check and the check is received by the claimant, the bank will not cash the check; this is frustrating for the claimant and causes complaints

This delays the check process even longer because now the claimant must wait for the second check to arrive


Branch Manager/Agent Involvement in Claim – Assisting Claimant

Claimant/Agent can submit claim paperworko If cancer claim, should send to PO Box 8080 McKinney, TX 75070-8080o If life claim, should send to PO Box 268892 Oklahoma City, OK 73126-8892


Branch Manager/Agent Involvement in Claim – Assisting Claimant

Or, claim can be sent in via fax (if original documents are not required); these are the fax numbers that belong to the Claims Dept. o If cancer claim, should fax to 214-544-5336o If life claim, should fax to 405-270-1496


Procedure for Claim Inquiries - Claimant

• Claimant should contact Liberty Customer Service for claim questions or status inquiries

Customer can call 205-325-4979 Customer can send written correspondence to

PO Box 8080 McKinney, TX 75070-8080 Customer can inquire via email through Customer

Service Express (click on “contact us” in website)


Procedure for Claim Inquiries – Branch Manager/Agent

• Branch Manager/Agent should contact Liberty Customer Service for claim questions or status inquiries

Branch Managers/Agent can send email inquiries to [email protected]

Customer Service answers inquiries within 48 hours If Customer Service can’t answer the question, it is

forwarded to Claims Dept. through an internal messaging system (still work to meet the 48 hour turnaround)

This is best and fastest way to ensure a response


Procedure for Claim Inquiries – Branch Manager/Agent

• Branch Manager inquiries sent to Customer Service should include

Policy number and insured name (telephone number is also helpful)

• Branch Manager inquiries should not be sent directly to Claims Department


Procedure for Claim Inquiries

• One of the most common inquiries is “Have you received the information that I sent in?”

Mail or faxes are not “logged in” as received until the claim reaches an examiner

On many occasions Customer Service will tell a claimant/Branch Manager that the system doesn’t show the claim information as received (in most cases, an appropriate amount of time has not elapsed to allow the information to reach a claims examiner) which causes frustration on the part of the claimant/Agent and duplicate claims to be sent in


Procedure for Claim Inquiries

The Claims Department processes claims in date received order so if our turnaround time is running 7 days, the claims information will not be logged into the system for approximately 7 days from the date the information was received by the company

The Claims Department works off of claim images instead of paper documents; need to allow adequate time for us to scan in the documents and put in a work queue for an examiner

tmk1536 0410agent training only. not for sales use. claims dawn mitchell senior vice president...

Documents