There is a problem that I see emerging and I don’t even know if it’s just emerging. It’s probably something that’s been going on for years before I ever got involved with this. It’s where the insurance company will undercut a plan of care that has been laid out for somebody and signed off on by that persons physician.
Basically, the way it works is when an individual needs care, in order to access policy benefits, they have to be assessed by a medical professional. That entails having somebody physically go to the home, take a look at the way the home is laid out and then observe the individual functioning within the home. Then they will assess the sort of needs they have. If they have difficulty walking, bathing and dressing or any of those things, a plan of care will be created as a result of that onsite evaluation and the plan of care will lay out what the professional believes is medically necessary for the individual. The individuals physician will look at it and either sign off on it or modify it to some extent. Then the care commences and the invoicing goes to the insurance company. The insurance company gets a hold of it and says no we don’t believe the person needs eight hours of care a day, we’re only going to approve four. So right away you’ve got a conflict between the insurer and insured person, where the person clearly has documented the need for eight hours of care and you have an insurance company obligated to pay for it saying we’re not going to pay for eight, we’re only going to pay four.
I see that as probably the biggest problem in the industry because that’s a problem that’s on the ground. It’s palpable. Somebody needs eight hours of care and they’re only getting four, something’s going to happen in those four hours that somebody is not there with them and things do happen. People fall down and get hurt and people who need that kind of care something is liable happen and things often do happen. Elderly people fall down and generally elderly people who have problems with walking and balance and so forth, if they fall on the floor they can’t get up, they’re stuck on the ground or on the floor. Not only that but when they fall they get hurt, they break hips and things like that.
So it’s a very serious problem and it’s the one thing that I take focus on very intensely because the idea of somebody being denied care that their doctors say they need because of money is something that’s abhorrent and should not happen. So that’s one of the problems.
Other problems that I think are significant is a lot of times as people age and they do start to lose some of their mental faculties, they may forget to pay their premium and the policy lapses. Well there’s a law in the state of Florida that recognizes that as people age, things do happen like that. So the law says that if a person lapsed their policy for non-payment because of some condition, giving rise to the need for care, that policy can be reinstated. I’ve had many people reinstated who got confused and didn’t pay their premium or something happened and that’s huge because once people reach that level, they become uninsurable. If they lose the policy then they’re going to have to pay for this care on their own and the costs of care are enormous. Most people can’t afford it. So that’s another component.
Another issue involves having; most of the policies that have been issued have a feature in them called a restoration of benefits, which is very important because essentially that provision in the policy can make the policy a perpetual policy. In other words, people buy a policy; some people buy a lifetime policy so restoration isn’t an issue. That policy will go on for life, but the majority of people don’t have lifetime policies, they have policies with certain time limits; two years, three years, five years, whatever the case is. With the restoration clause somebody can be on claim for three years, reach the end of the claim period and then restore back to their original benefits if they do certain things that the policy requires them to do, essentially go without care for 180 consecutive days, that policy will restore and they’ll get another full period of benefits. A lot of people don’t know that and I’ve seen the insurers simply not apply it or refuse to apply it or make an issue out of applying it and people accept that and they think their policy is over when its actually not and that’s a very big issue.
Yet another issue I see a lot is when the insurance company just short pay. That simply means that the home health agency or registry provides $100 worth of care, they send the invoice so the insurance company and the insurance company pays $80. For no good reason other than they can do it. For years and years they’ve gotten away with it because the providers don’t have the wherewithal to pursue the balances and more often than not the registries and agencies are looking to the insured person, the person who needs the care, to cover the difference. That’s pressure because now these insured people have to find the money to cover the difference. We’ve collected well in excess of $1 million of accounts that were short payed. That alleviated not only the pressure from the provider being short payed but also the pressure of the provider looking to the insured person to pay the difference. That is a benefit that we’ve been able to get for people.