Claims & Underwriting
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1 Claims & Underwriting Medical Directors Forum Musculoskeletal Disease Case Studies Wayne Heidenreich, MD Medical Director, Northwestern Mutual Marjorie Keymer, MD VP & Medical Director, Genworth Financial Claims Jennifer Vey, RN AVP Claim Management, TriPlus Services, Inc.
2 Case 1 Case 1 How Did This Happen? Medical Directors Forum Musculoskeletal Disease Case Studies 2
3 Case 1 Underwriting Application 65 y.o. female. No admitted tobacco use 5 5 # 110 with BMI of 17.8 No cardiovascular risk factors Admitted History: Arthritis Works Full Time - Collections for Attorneys Never missed work due to Arthritis No limitations to Activities of Daily Living No Joint Infection in past 24 months No Large Joint Surgery in past 12 months No Active Rehabilitation Program No Compression Fractures Admitted Medications: Arthrotec for Arthritis Minocycline for Arthritis Fosamax and Calcium for Back Prescribed by specialist, not primary MD Medical Directors Forum Musculoskeletal Disease Case Studies 3
4 Case 1 Underwriting PCP Medical Records Primary Care Medical Records 1 month Prior to Application (PTA): Doing well since IA steroid left knee Exam with full ROM 7 month PTA: Small effusion left knee Reference of Rheumatoid knee IA steroid Considering Methotrexate with rheumatologist 15 month PTA: Right knee injury resulting from a fall 4 months earlier 2 more falls attributed to pain in knee Allergic to Arava Moderate right knee effusion IA steroid Medical Directors Forum Musculoskeletal Disease Case Studies 4
5 Case 1 Claim First Notice 2 years post-issue Daughter calls in: Policyholder fell on ice and fractured pelvis two months ago Was living ing at home alone for 1 month after fall, until increasing pain caused her to move in with her son to recuperate Increasing pain led policyholder to seek medical care Diagnosis of fractured coccyx and pelvis 1 month later policyholder is moving to an ALF: After 3 weeks in Rehab with a great response, she has decided she will move to an ALF. Benefits not being pursued. Medical Directors Forum Musculoskeletal Disease Case Studies 6
6 Case 1 Claim Second Notice 6 months after move to ALF, daughter reports policyholder needs help dressing and bathing Benefit Eligibility Assessment and Facility notes confirm unsteady use of walker, unable to lift arms above chest, requires assist with dressing and bathing Is not claiming back to event of broken pelvis Described as stoic After pelvis fracture, she tapered herself down from six Vicodin per day to 1 Vicodin in am to allow her to get moving Medical Directors Forum Musculoskeletal Disease Case Studies 7
7 Case 1 Claim Second Notice continued Claim information: Rheumatology Medical records: 25 year history of Rheumatoid Arthritis started in her 40 s Severe deformity of hands due to ulnar deviation and erosive disease with subluxations In past was on hydroxychloroquine, leflunomide, then trial of minocycline At time of evaluation in ALF was on: Methotrexate 15 mg q week Vicodin 5/500 bid prn Fosamax Information known at underwriting : Primary Care Medical Records Left Knee: IA steroid injection Small effusion Reference of Rheumatoid knee IA steroid Considered Methotrexate with rheumatologist Right Knee: Injury resulting from a fall 4 months earlier 2 more falls attributed to pain in knee Moderate effusion IA steroid Medical Directors Forum Musculoskeletal Disease Case Studies 8
8 Case 1 Closure of Claim After 7-years, claim is closed upon death of policyholder Policyholder was 75 years old with Alzheimer s and Rheumatoid arthritis at time of death Policyholder had had 2 hospitalizations in her last 3 months of life Medical Directors Forum Musculoskeletal Disease Case Studies 10
9 Case 2 Case 2 It All Adds Up Medical Directors Forum Musculoskeletal Disease Case Studies 11
10 Case 2 Underwriting Application Admitted history 73 y.o. male. Non-smoker lbs. with recent 14 lb. weight loss due to exercise Prescribed medication for hypertension and prostate symptoms 3 months PTA had successful hammer toe surgery Medical Directors Forum Musculoskeletal Disease Case Studies 12
11 Case 2 Underwriting PCP Medical Records Primary Care Medical Records Hypertension, Kidney Stones, Diverticulitis, Benign Prostatic ti Hypertrophy Degenerative Joint Disease Bilateral bunions with hallux rigidus 2 nd left Hammer toe repair Knee arthritis noted 5 years PTA Left knee: Loose bodies Right knee: Patellar-femoral syndrome Left Total Hip Replacement noted 2 years PTA Concurrent with application, low back x-ray: indication back pain but no symptoms documented in notes Taking no arthritis medications at time of application Medical Directors Forum Musculoskeletal Disease Case Studies 13
12 Case 2 Underwriting PCP Medical Records (con t) Primary Care Medical Records (continued) Grieving over death of wife 9 months PTA Recognizes need for socialization so returned to working parttime in an ice cream truck Insomnia treated with clonazepam at night 3 months PTA had intermittent fatigue throughout day attributed to poor sleep and hypoglycemia (significant Glucose Tolerance Test finding of low blood sugar of 46 at 3 hours with symptoms) 3 months PTA new onset of migraines i with high h anxiety level l over impending cruise Medical Directors Forum Musculoskeletal Disease Case Studies 14
13 Case 2 Underwriting FTF Assessment Face to Face Assessment After death of spouse, daughter moved in to home with husband and 2 children Retired 11 years Drives daily: 10,000 miles per year Hobby: model building 1-2 hours per week Exercise: walks 5 miles/day; 1 hr weights at home MMSE 28/30 with DWR 4 No TGUG done at time Medical Directors Forum Musculoskeletal Disease Case Studies 15
14 Case 2 Claim Notice 11 years after issue at age 84, Application for Benefit received Policyholder has sold house, moved into ALF Claimant Statement on Application for Benefit: Facility records document assistance with bathing and dressing Benefit Eligibility Assessment documents fragility Medical Directors Forum Musculoskeletal Disease Case Studies 17
15 Case 2 Claim Medical Records Interim Medical Records Bilateral Total Knee Replacement 2 and 3 years Prior To Claim (PTC) Left Total Knee Replacement redo 1 year PTC Lumbar laminectomy with persistent low back pain in year PTC with the following treatments: Epidurals PT No heart disease No diabetes No cognitive impairment Medical Directors Forum Musculoskeletal Disease Case Studies 18
16 Case 3 Case 3 We Can t tanticipate i t it all Medical Directors Forum Musculoskeletal Disease Case Studies 20
17 Case 3 Underwriting Application 55 y.o. female. No admitted tobacco use in last 10 yrs #140 with BMI of 17.8 No cardiovascular risk factors Admitted History: Mild arthritis, may take ibuprofen a few times per year; no prescriptions. (Never been diagnosed by anyone) No other admitted medications Works on family farm Medical Directors Forum Musculoskeletal Disease Case Studies 21
18 Case 3 Underwriting Medical Records (1) Attending MD Records Primary Care Concurrent office visit: Asthma, doing well on medication regimen of Advair, Singulair and as needed Albuterol. Intermittent mild symptoms of shortness of breath with activity and weather changes 12 months PTA CXR showed bilateral fibrosis Left > Right 19 months PTA asthma flare treated with prednisone taper Could hardly move Was referred to a rheumatologist due to family history of lupus (3 sisters) and mildly elevated ANA and sedimentation rate Medical Directors Forum Musculoskeletal Disease Case Studies 22
19 Case 3 Underwriting Medical Records (2) Rheumatologist Medical Records 19 months PTA Rheumatology review of joints Pain in multiple joints bilateral shoulders, elbows, hands Hobbies: reading and walking Pain in all joints including both hands: Right>Left; No swelling, redness or warmth RA factor, CMV, Epstein-Barr and Parvo virus all negative C-reactive protein low Impression: Cannot entirely rule out early rheumatoid arthritis presentation Continue non-steroidal prescription like ibuprofen Return as needed for discomfort or inflammation of hand joints Did not return to rheumatologist Medical Directors Forum Musculoskeletal Disease Case Studies 23
20 Case 3 Claim Notice 11 years after issue, application for Benefit received: Recent onset of severe back and leg pain Difficulty walking Benefit Eligibility Assessment Demonstrates need for assistance with bathing, transferring, toileting, and dressing Medical Directors Forum Musculoskeletal Disease Case Studies 25
21 Case 3 Claim Medical Records Rheumatology Medical Records Past Medical history: Exam: Bilateral knee replacements and multiple falls Chronic back pain for years, gradually worsening 1 month PTC increased low back pain radiating to left leg, significant pain at rest, intensifying with raising, standing and ambulation MRI: significant stenosis at L4/L5 Normal gait, able to walk on heels and toes and tandem Treatment: Percocet and conservative therapy, epidural No surgery planned because major problem is pulmonary disease Pulmonary Medical Records Generalized fatigue, frailty and multiple falls Diagnosis of idiopathic pulmonary fibrosis on biopsy On O 2 Medical Directors Forum Musculoskeletal Disease Case Studies 26
22 Case 4 Case 4 We Won t Be Fooled dagain! Medical Directors Forum Musculoskeletal Disease Case Studies 28
23 Case 4 Underwriting Application 60 y.o. female # with BMI of 25.7 Non-smoker Not currently employed Admits to two Physicians Primary care Rheumatologist seen 30 months ago for psoriasis No admitted arthritis or treatment with arthritis medications Medical Directors Forum Musculoskeletal Disease Case Studies 29
24 Case 4 Underwriting Rheumatology Records Rheumatology Consult 30 months PTA Past medical history: Carried diagnosis of rheumatoid arthritis Long-standing psoriasis Intermittent pain in left side - knee, hip, shoulder; occasional discomfort bilateral feet Treated with Methotrexate, prior treatment with Humira Current complaints of morning stiffness in hands; chronic neck and elbow pain Exam: Limited range of motion neck and left shoulder, fluid in left knee; tender left hip and right foot MRI of shoulder: severe erosive disease, bone on bone, bicep tendon swelling Impression: Osteoarthritis and Psoriatic arthritis Treatment plan: Complete a series of x-rays to assess for active synovitis/psoriatic arthritis if positive start infliximab with the methotrexate; Physical Therapy for shoulder Steroid injection for left hip NSAIDs as needed Medical Directors Forum Musculoskeletal Disease Case Studies 30
25 Case 4 Underwriting Pharmacy Records Pharmacy records Show eligibility through the time of underwriting going back 6 years. Methotrexate prescriptions last filled 24 months ago Most recent prescription for an anti-inflammatory inflammatory is 24 months PTA for indomethacin Migraine meds with occasional opioid (Tylenol with codeine) Does see a dermatologist who started treatment with a biologic, Stelara (ustekinumab) started 24 month ago No evidence of follow-up Medical Directors Forum Musculoskeletal Disease Case Studies 31
26 Questions Medical Directors Forum Musculoskeletal Disease Case Studies Questions/Comments Medical Directors Forum Musculoskeletal Disease Case Studies 33
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