An area of increasing importance to insurers is that of long term care claims administration. The frequency of claims is increasing given age-dependent demographics.


Long term care policies are different than group health or disability policies with respect to setting, level and types of care. They have important coverage differences, e.g., nursing/residential facility only vs. home care only vs. comprehensive policies that include both.


Ultimately, in functional terms one must consider impairment in activities of daily living and/or impairment in cognitive function. Determination must be made as to appropriate care as well as what is actually covered by the policy.


With more than 20 years in the medical review industry, we are a company with a large multispecialty board certified physician panel. Our panel has extensive experience dealing with cases involving skilled and custodial care, home care, and activities of daily living. Our long track record in group health, Medicare and disability review sets the foundation for successful long term care review.  



Specific review areas include:


  • Activities of daily living
  • Skilled, intermediate and custodial care
  • Home health care, personal care and homemaker services
  • Hospice services and respite care
  • Adult day care, nursing facility and residential care facilities
  • Coordination of benefits with Medicare, Medicaid, and health insurance
  • Review of medical notes and records
  • Review of surveillance data