Long Term Care Law Office Blog

The Importance Of Following a Plan Of Care (And Why It Doesn’t Always Happen).

Written by Steven Dunn in category 
November 4, 2016

A serious issue that I have encountered in the long term care world is when an insurance company undercuts a plan of care for an insured person. Oftentimes, even though a plan of care has been approved by an insured’s physician, the insurance company will disagree with the amount of care hours assigned. This is probably one of the biggest problems in the industry because there is a lot at stake for everybody.

Allow me to explain.

How care hours for Long Term Care are determined (and how they can change without you knowing why).

When an individual needs care, they have to be assessed by a medical professional in order to access policy benefits. The assessment entails a home visit, where the professional observes how the individual is currently functioning within the home. They assess their needs based on how they perform basic activities of daily living such as walking, bathing, and dressing, etc. They then create a plan of care with what they deem medically necessary for the individual based on the onsite evaluation. Once the individual’s physician modifies and/or signs off on the plan of care, care commences and the insurance company receives the invoices. 

If an insurance company deems the number of care hours in a plan of care unjustifiable (which happens often), then they will undercut it. This means that somebody who may need eight hours of care is now only getting four. Something could very well happen in the four hours they go um-monitored, and oftentimes, something does. Elderly people are inevitably more at risk for falling and injuring themselves, and many of them are unable to pick themselves back up if they do have a fall. Clearly, there are a lot of potential liabilities in these scenarios that can and should be avoided with the proper adherence to a set plan of care.  

This is a very serious problem that I have encountered in the Long Term Care world, and one that I focus on very intensely. It is important that providers, caregivers, and the family members of insured people are aware of this potential obstacle, so that if need be, they can seek out the best way to rectify it.

If you are having a problem with undercut care hours or any other issue with your Long Term Care Policy you can always contact us for a policy review.

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