Retrospective Reviews for past periods of care – avoiding fatal mistakes

Retrospective Reviews for past periods of care – avoiding fatal mistakes

Q. How do you know when you’ve won your retrospective claim for CHC Funding?

A. When you get paid!

Here’s a question recently posted by Helen on our Facebook page dealing with just this issue:

Following a 4-year battle for retrospective CHC healthcare funding for my late father who suffered with Alzheimer’s, the decision finally went in our favour, and the initial decision of his ineligibility was reversed. Sadly, as with most retrospective claims it has been a long, stressful and protracted journey, not least because my mother is 89 years old and I desperately want to see the money owed to her refunded ASAP. The problem is that they are asking for bank account statements or nursing home invoices demonstrating payment which we no longer have!! Following my father’s death in 2007, my mother destroyed much of his paperwork understandably. Has anyone else been in this position, could I ask and, if so, how was this resolved?”

 Thank you, Helen, for sharing your question.

Unfortunately, this is a common scenario.

Clinical Commissioning Groups (CCGs) are becoming more pedantic about the type of evidence that your relative will need to produce in order to obtain reimbursement of care home fees that were improperly charged if your retrospective review is successful.

The mere fact that the CCG has retrospectively agreed that your relative was eligible for NHS Continuing Healthcare Funding for a particular period of their care, is not the end of the matter.

As in Helen’s situation, it can take many years for the CCG to reach a decision to grant CHC Funding, but you now have to prove the amount of reimbursement due. Depending upon the length of the claim period, sometimes reimbursement can be a very significant amount (plus interest) – tens, possibly even hundreds of thousands of pounds!

As the burden of proof is on you, don’t expect the CCG to help you out!

What evidence will you need?

You will usually need to produce:

  1. Invoices from the care home to show the sums that were charged.
  2. In addition, a detailed Statement of Account from the care home to show what sums were actually paid, and when, in order to check that payment tallies with the invoiced amounts; plus
  3. Bank statements for the relevant claim period to confirm that monies were actually paid to the care home.

As we know, difficulties can arise if the care home has poor accounting procedures and practices, and insufficient or inadequate record keeping. The issue can be even more problematic if the care home has closed down and you need to track down the financial records.

If the care home is still in existence but has poor record keeping practices, then at least there should be some evidence available to prove what has been invoiced and paid, in terms of your relative’s care. However, where the care home has closed down, or perhaps been demolished, getting hold of the financial records might prove an uphill task. In some cases, you may never get these records at all to support your claim – even if the retrospective claim is successful.

Therefore, if pursuing an historic, retrospective claim, going back many years, ensure that you have all these records at the outset (when you start your claim).

These retrospective claims can take many years to reach a final outcome. We recommend that you get all the financial records in place at the outset in anticipation of a successful outcome, rather than wait to see if the outcome is favourable before rushing around to obtain the records. As in Helen’s case, it could be too late.

We often find that families unwittingly throw away this vital financial evidence after their relative has passed away, believing it not to be relevant anymore. Alternatively, surviving family members don’t have sufficient authority to apply for the invoices, Statements of Account or bank statements, which then delays matters whilst they have to incur costs and time in obtaining the necessary authority.

Our top tips:

  • It is better to get the evidence you will need in advance, but remember to keep it safe.
  • Keep copies of bank statements, as they are a great source of proving what fees have been paid to the care home.
  • Note that some banks e.g. Barclays, only keep records for up to 6 years.

What happens if you simply don’t have any evidence whatsoever to prove your loss?

Take Helen’s unfortunate scenario, or even another scenario, where the individual has long since passed away and the care home no longer exists. You have searched everywhere for invoices, a Statement of Account, and there are simply no bank statements you can get hold of due to the passage of time.

If your relative was self-funding their care/nursing home fees, it can be easier to argue that the care home would certainly not have kept your relative in these (plush) surroundings without any payment for their healthcare and accommodation needs.  Don’t forget, most care homes are run as a business, and if someone can’t afford to pay, you can expect that the care home will turf them out to make room for another resident who can pay.  So, whilst only circumstantial, you can argue this as a starting point that your relative must therefore have been paying something towards their care fees!

But, it still does not prove the actual amounts paid, nor help with the calculation as to the sums to be reimbursed.

As a default position, if you really don’t have any documentation, you could argue that the CCG would have paid the care home a minimum ‘bed rate’ for your relative’s care pursuant to contract with that particular care home.  Whatever that bed rate is for the period of claim, it should form the absolute minimum amount that the CCG would have paid per week/month for your relative’s healthcare needs.  Simply multiply that minimum rate by the assessed retrospective claim period to calculate your relative’s loss.

For example, the CCG pays a care home £850 per week. Mrs Jones was found eligible for NHS Continuing Healthcare Funding for the period 1st January 2015 to 31st December 2015 (52 weeks). So, £850 x 52 weeks = £44,200.

Don’t forget, you are also entitled to claim interest on that loss based on the Retail Price Index.  The CCG will ordinarily do that calculation for you. The calculation can be tricky to understand and check. If you are unsure, ask the CCG to explain how they have arrived at their settlement figure.

Read our helpful blog on claiming interest: Can I claim interest on my refund of care fees paid?

Of course, it is quite possible that your relative’s care home fees may well have far exceeded the lower rates payable by the CCG to the care home – but without any additional proof, you may simply have to accept this lower rate if offered, which is at least some reimbursement of the care costs paid.

Where there is just no evidence to support your relative’s losses, this may be the best outcome you can hope for.

Tip: Ask the CCG (or the care home) for a copy of the contract between the two organisations to see what rates the CCG were paying towards the CHC funded cost for other residents in that care home by way of comparison/proof.

Remember:  If your relative has passed away, then you will need authority to act on their behalf to obtain these financial records, correspond with the Clinical Commissioning Group and care home, and to approve and receive any retrospective settlement award.

If your relative has left a Will, then the Executors appointed under the Will can provide a Grant of Probate as their authority to act. You may wish to seek financial advice before taking out the Grant.

If there is no Will, then the Intestacy rules apply, and a Grant of Letters of Administration will need to be applied for.  This can be time consuming, and equally, there may be tax implications.  Again, you may wish to seek financial advice.

For further reading on the subject, read:

Why you should consider making Lasting Power of Attorney or a Will

I have a will, so why do I need a Lasting Power of Attorney?

If your relative is still living, then you will need to produce a certified Lasting Power of Attorney, appointing you as your relative’s Attorney to deal with their financial and health affairs.  For further information on Powers of Attorney, we recommend you read our blogs:

Essential: Have You Got A Power Of Attorney?

If you need help with drafting a Will or Lasting Power of Attorney, visit our one-to-one page.

For general reading on the subject, read our recent blog:

In the press recently – “Four seasons healthcare goes into administration

Summary:

Once you have decided to make a retrospective claim, plan ahead, look at the evidence your relative is going to need, get it promptly and keep it safe! Remember that you are entitled to interest on your reimbursement. Remind the CCG, that the longer they delay making payment, the more interest is accruing out of their budget.

Leave a comment below, or share your story and help others…

3 Comments

  1. Jennie 1 month ago

    My advice is not only to get invoices but all the medical care home records before you make the claim then you will have the same information the CCG has. Answer to final question.They try to make savings on all cases no matter what the amount but consider if they made savings on interest of a claim worth £100,000, it would be worth the while of staff to do it and I assume with targets in mind , staff are mindful to show any savings on claims paid.

    • Jenny 1 month ago

      Looks like they’re not interested in doing that Jennie. I’ve waited long enough and have now issued process for the debt due on the retrospective eligibility claim, so that’s 8% interest from the time they had all the proof of bills paid (just under £100,000) to judgement and beyond, plus the court fee which is nearly £5000. Scandalous waste of funds, when all they need to do is establish and enforce a reimbursements payments policy and communicate – like any normal body or business. It’s either incompetence or intransigence.

  2. Jenny 2 months ago

    Another helpful and practical article. Thank you. It’s also worth noting that even when you have all the information they require and you send it by Signed For post, they still won’t commit to reimbursement swiftly. Because I had waited many months for repayment of fees paid whilst waiting for the DST outcome when my relative was living, I pushed for 28 days payment on the retrospective finding – as is normal in a commercial transaction where a debt is proved as owing. I was eventually told it could take 9 weeks.
    So far I’ve received an email saying the interest calculation is complete. But that was many weeks ago, and I still haven’t received their workings. If nothing further happens, and the 9 weeks passes without payment, I’m minded to claim the whole lot via the County Court, claiming Court rate interest not RPI. At that point I’d expect the claim to be c £100,000.
    Why do they waste so much time and money?

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