complaint·October 21, 2024

On 04/09/2024, LPA conducted a complaint investigation visit to the facility above. During this visit, LPA requested and received relevant documentation pertinent to the complaint allegation for record review. LPA additionally interviewed both staff of the facility and residents in care at the facility during the complaint investigation visit. LPA received documents from the facility including an insurance claimant care needs assessment form to be completed by a licensed clinician to process a resident’s long-term care claim, insurance continued monthly residence form required as part of a monthly claim submission, an insurance company facility form regarding a claim for charges covered by the facility, insurance company facility verification form, insurance monthly verification form to be completed each month after services have been rendered, and insurance confinement form providing benefits on behalf of a resident based on residency in the facility. Each insurance form received by LPA from the facility is between 1-2 pages in length and all forms require dates and signatures from facility staff and/or a professionally licensed clinician. Each insurance form has multiple sections and/or questionnaires required to be completed that include resident information, facility information, provider information, and licensing information. Staff of the facility stated during their interviews with LPA that, beginning 05/01/2024 residents will be charged $150 when they submit forms or paperwork to the facility office to complete insurance paperwork so they can receive services from their long-term care insurance. According to Staff, the facility medical director sees approximately 12-15 residents, while most residents are seen by their own primary care physician (PCP). The census at the time of the initial complaint investigation visit by LPA was 350 residents in the facility. Staff stated to LPA that it takes about 3-4 hours a month to complete paperwork for each resident. Paperwork is usually completed by the residents' own PCP. A long-term care medical technician from the insurance company is first sent to do an assessment of the resident for eligibility and the assessment is then sent to an insurance adjuster for consideration. The services must be re-certified every 6 months to 1 year. The residents receive a monthly invoice for these services. Per Staff, the residents can complete their own insurance paperwork. The facility office completes only, if necessary, sections of the insurance forms such as: Can the resident remain in the same apartment for the entire month, were they hospitalized in the last month 1st - 30th, description of current apartment - Memory Care, Skilled Nursing, Assisted Living, and is any of the amount covered by Medicare or private pay. Report Continued on LIC9099-C. The residents are charged the $150 only if their insurance paperwork needs to be completed. The facility also provides the insurance company with a plan of care, copy of the Medication and Administration Record (MAR) log, and copy of the facility license. The $150 is charged only if a resident needs a portion of their insurance paperwork completed, and not just for sending out the insurance invoice. The $150 charged by the facility for the completion of medical insurance paperwork has nothing to do with receiving required medical services. Facility staff stated to LPA that insurance claims are requested by the resident or their representative/responsible party if the resident needs care and is living in assisted living setting. The process is started when a registered nurse (RN) provided by the insurance company is sent out to assess the resident. A letter is then sent to the resident and/or their representative/responsible party. According to all staff interviewed by LPA, the insurance company itself does not speak with the facility. The RN provided by the insurance company will make recommendations to the facility such as the provision of a shower chair or obtaining a better walker. The facility and insurance RN will discuss what additional services or equipment is needed for the resident. The medical evaluation for the resident is completed by the insurance RN. Long-term services for Activities of Daily Living (ADL) such as bathing, clothing, toileting, feeding, and hygiene are reimbursable for the resident, but if they do not follow the service process, then there is no reimbursement. LPA interviewed multiple residents at the facility who stated that they are assisted and transported to their PCP with their medical services scheduled by their representatives. Other residents interviewed by LPA indicated that they have not been charged for insurance paperwork. Residents stated to LPA that they receive a bill from the facility with charges that are warranted. They are not aware of the facility providing false insurance documents to receive medical services. Residents interviewed by LPA stated that they receive appropriate medical services from their physician. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Exit interview conducted. Copy of this report provided to the facility.