The Long Term Care (LTC) market has changed significantly in recent years. The traditional indemnity product model has moved towards the medical model with re-imbursement payments linked to a Plan of Care.

When a claim is submitted a needs assessment is completed in the Intake Department to access Activities of Daily Living (ADL) and cognitive assessment. Additional data is also collected on the claimant’s background, including home environment and current services, to provide a bigger picture. This will be used as the basis for creating the Plan of Care.

The Plan of Care is a key component in today’s LTC claim process. It is a list of long term services developed by a Care Coordinator or other licensed health care practitioner. From a payment perspective there is a level of complexity with support required for multiple benefit options to support the re-imbursement model. Each benefit option has a maximum benefit associated with the invoice. If the invoice is more than the benefit amount as defined in the LTC plan the claimant will have to pay the additional amount.

ClaimVantage has addressed this payment model by supporting multiple benefit option per plan and per payment. This is critical to support the Plan of Care. The JBoss Rules engine plays a critical part in setting up the relationships between the benefit payment option, the policy plan and received invoice. Many rules are required to address each Plan of Care but the benefit of this is that each rule set can be copied and reused for additional Plan of Care for other claimants.

The claim process, and specifically the Plan of Care, needs to be monitored and reassessed on a regular basis to ensure that it continues to meet the needs of the claimant. The Care Manager needs to maintain regular contact with the insured, his/her family and all other parties involved in the process.

ClaimVantage understands the need to monitor and keep in contact with relevant parties. To do this effectively ClaimVantage uses the JBoss Workflow system to schedule to-do activities, follow up calls and reviews. This key process ensures that the claimant is receiving the correct level of care and that the correct payment amounts are been paid according to the Plan of Care.