Question
I am a mental health provider in Louisiana with a provider contract with Humana and Corphealth, Humana's subsidiary covering mental health claims. I was already a provider with Humana when in 2007 I was made aware of their Medicare Advantage plan. I immediately contracted with Corphealth to work with Humana Gold Plus HMO since I was already working with many Medicare clients. Starting with the first claim I submitted in January of 2008, I have had every claim denied for payment by Humana with the denial being because I did not have a referral from the Primary Care Physician. I called Humana to inquire about the denials and I was told in Louisiana there is no requirement for the referral. We are the only state with this exclusion. (I recently found out this is because of Hurricane Katrina--LA residents were scattered across the country and could not get to their PCP's for referrals). So, I make a call when I received the denial and a claims rep states "you are right--you do not need a referral." The claim is resubmitted and paid about 2 weeks later. Again, I go through this with every claim! Now, in April, something changed. No, they did not fix their system to accommodate their own policy. They stopped fixing my claims and stopped paying. I have called provider relations, claim specialists for both companies. Yes, I am right, I do not need a referral. Please re-submit your claim but send it directly to this fax number and it will be taken care of. No, send it to this fax number. No payment received and further denials. It is now the end of August and I still have claims from April unpaid. So, I get tired of this runaround and contact the Insurance Commission office for Louisiana. They refer me to a person in CMS. He takes my complaint and sends Humana a complaint in my name. My question is why is this problem continuing since 2007? Why has Humana continued to refuse to actually fix what would seem an easy problem to fix? Is the part of their apparent reputation of not paying claims? But, most importantly, what else can I do? I know I have more than one question here but I am so frustrated! I have a small solo practice and I personally handle my own claims. I plan on quitting Humana but I want my money first. Sorry to run on. Thank you.
Answer
This is really outside of my expertise, since the regulations are different than in Louisiana than they are in my state.. You might contact the SHIP program in your State at 1-800-259-5201 and request to speak with a counselor who is an expert in Advantage plan appeals.You will get their nearest office, and they will know any special regulations for that State.
Around here we have a special number for most of the the plans so we can call a specific person in the plan. I do not know if that is true in all the
states, but they may have the same setup.
The Advantage plans have to give the client a packet of information containing what is referred to as a Certificate of coverage. When the person gets a denial they should follow the appeal process outlined in that packet, and if it is still denied go another step forward with the process. The plans rely on the patients not knowing how to properly appeal. Usually rather than keep getting time lost fighting appeals, they pay.
Sorry I could not be of much help.
John
Tuesday, March 16, 2010
Medicare/no fault auto insurance
Question
I fell and broke my wrist, I went to the hospital, then was referred to a Clinic, where I saw 2 different doctors, and they did surgery on my wrist. It was billed and paid through medicare. A few months later, I thought maybe my auto insurance would cover it, because it happened when I got caught up in my seat belt, and fell out of my car. I called my auto insurance, and they said they would cover it. They got ahold of medicare, and started the process with MSPRC. They called the clinic, and asked for a copy of their billing. They sent them a copy of the billing (not showing that medicare had already paid, or that they were billed). The insurance company (state farm) computer starting sending them checks. The checks totaled my entire entitlement, 10,000.00. MS{RC has now sent a lein letter to my insurance company, but there is no money left. State Farm, MSPRC, and Medicare have said the doctors office needs to return those checks, that they have already been paid in full by medicare. The total that State farm owes MSPRC is about 3200.00. The doctors office won't call MSPRC, they said they would not refund the money until they get it in writing from medicare, and they do not see that MSPRC and medicare and NOT one and the same. HELP!! Thanks
Answer
Hi Kathy
This is really a legal question and outside of my expertise.
BUT, maybe this might work for you. Call 1-800-Medicare..When answered you will be on the press the button section. ASAP say AGENT. You be transferred to the representative talk session. When that is answered request to speak to a claims specialist in reference to a claim that has been paid twice. Do not call on Monday or early in the morning or you will be on the phone all day. Have all the information you have ready when you call. The claims representative is the office that sends out those letters you are looking for.
I am not familiar with the legal actions that might be needed.
Hope this is some help.
John
I fell and broke my wrist, I went to the hospital, then was referred to a Clinic, where I saw 2 different doctors, and they did surgery on my wrist. It was billed and paid through medicare. A few months later, I thought maybe my auto insurance would cover it, because it happened when I got caught up in my seat belt, and fell out of my car. I called my auto insurance, and they said they would cover it. They got ahold of medicare, and started the process with MSPRC. They called the clinic, and asked for a copy of their billing. They sent them a copy of the billing (not showing that medicare had already paid, or that they were billed). The insurance company (state farm) computer starting sending them checks. The checks totaled my entire entitlement, 10,000.00. MS{RC has now sent a lein letter to my insurance company, but there is no money left. State Farm, MSPRC, and Medicare have said the doctors office needs to return those checks, that they have already been paid in full by medicare. The total that State farm owes MSPRC is about 3200.00. The doctors office won't call MSPRC, they said they would not refund the money until they get it in writing from medicare, and they do not see that MSPRC and medicare and NOT one and the same. HELP!! Thanks
Answer
Hi Kathy
This is really a legal question and outside of my expertise.
BUT, maybe this might work for you. Call 1-800-Medicare..When answered you will be on the press the button section. ASAP say AGENT. You be transferred to the representative talk session. When that is answered request to speak to a claims specialist in reference to a claim that has been paid twice. Do not call on Monday or early in the morning or you will be on the phone all day. Have all the information you have ready when you call. The claims representative is the office that sends out those letters you are looking for.
I am not familiar with the legal actions that might be needed.
Hope this is some help.
John
Posted by
zhengyun jin
Humana Gold Plus HMO
Question
QUESTION: I am a mental health provider in Louisiana with a provider contract with Humana and Corphealth, Humana's subsidiary covering mental health claims. I was already a provider with Humana when in 2007 I was made aware of their Medicare Advantage plan. I immediately contracted with Corphealth to work with Humana Gold Plus HMO since I was already working with many Medicare clients. Starting with the first claim I submitted in January of 2008, I have had every claim denied for payment by Humana with the denial being because I did not have a referral from the Primary Care Physician. I called Humana to inquire about the denials and I was told in Louisiana there is no requirement for the referral. We are the only state with this exclusion. (I recently found out this is because of Hurricane Katrina--LA residents were scattered across the country and could not get to their PCP's for referrals). So, I make a call when I received the denial and a claims rep states "you are right--you do not need a referral." The claim is resubmitted and paid about 2 weeks later. Again, I go through this with every claim! Now, in April, something changed. No, they did not fix their system to accommodate their own policy. They stopped fixing my claims and stopped paying. I have called provider relations, claim specialists for both companies. Yes, I am right, I do not need a referral. Please re-submit your claim but send it directly to this fax number and it will be taken care of. No, send it to this fax number. No payment received and further denials. It is now the end of August and I still have claims from April unpaid. So, I get tired of this runaround and contact the Insurance Commission office for Louisiana. They refer me to a person in CMS. He takes my complaint and sends Humana a complaint in my name. My question is why is this problem continuing since 2007? Why has Humana continued to refuse to actually fix what would seem an easy problem to fix? Is the part of their apparent reputation of not paying claims? But, most importantly, what else can I do? I know I have more than one question here but I am so frustrated! I have a small solo practice and I personally handle my own claims. I plan on quitting Humana but I want my money first. Sorry to run on. Thank you.
ANSWER: This is really outside of my expertise, since the regulations are different than in Louisiana than they are in my state.. You might contact the SHIP program in your State at 1-800-259-5201 and request to speak with a counselor who is an expert in Advantage plan appeals.You will get their nearest office, and they will know any special regulations for that State.
Around here we have a special number for most of the the plans so we can call a specific person in the plan. I do not know if that is true in all the
states, but they may have the same setup.
The Advantage plans have to give the client a packet of information containing what is referred to as a Certificate of coverage. When the person gets a denial they should follow the appeal process outlined in that packet, and if it is still denied go another step forward with the process. The plans rely on the patients not knowing how to properly appeal. Usually rather than keep getting time lost fighting appeals, they pay.
Sorry I could not be of much help.
John
---------- FOLLOW-UP ----------
QUESTION: That is okay. I have contact the SHIPP office in Louisiana and they referred me to a specialist in Medicare.
It sounds like you are saying that it is the responsibility of the consumer, my client, to ultimately get these claims paid? As the provider, I thought it was my responsibility.
Answer
Hi Leigh
As usual, there are no hard and fast lines as to who is responsible for claim payment.
The provider is responsible for knowing what is covered. which code to use. and informing the patient when something will not be covered, and submitting the claim to the right place.
The patient is responsible for appealing any claim denials.
They have to work together when there is a problem.In this case Humana is not following the proper regulations. That is where human failure comes in. Thy do not report fraud and abuse like they should. For providers it is found in the CMS Providers Manual, For the bennie it is on the back of the Summary Notice they get. When CMS gets enough complaints, they sanction the insurance plan like Humana.
We appreciate people like you who try hard to get it straightened out.
John
QUESTION: I am a mental health provider in Louisiana with a provider contract with Humana and Corphealth, Humana's subsidiary covering mental health claims. I was already a provider with Humana when in 2007 I was made aware of their Medicare Advantage plan. I immediately contracted with Corphealth to work with Humana Gold Plus HMO since I was already working with many Medicare clients. Starting with the first claim I submitted in January of 2008, I have had every claim denied for payment by Humana with the denial being because I did not have a referral from the Primary Care Physician. I called Humana to inquire about the denials and I was told in Louisiana there is no requirement for the referral. We are the only state with this exclusion. (I recently found out this is because of Hurricane Katrina--LA residents were scattered across the country and could not get to their PCP's for referrals). So, I make a call when I received the denial and a claims rep states "you are right--you do not need a referral." The claim is resubmitted and paid about 2 weeks later. Again, I go through this with every claim! Now, in April, something changed. No, they did not fix their system to accommodate their own policy. They stopped fixing my claims and stopped paying. I have called provider relations, claim specialists for both companies. Yes, I am right, I do not need a referral. Please re-submit your claim but send it directly to this fax number and it will be taken care of. No, send it to this fax number. No payment received and further denials. It is now the end of August and I still have claims from April unpaid. So, I get tired of this runaround and contact the Insurance Commission office for Louisiana. They refer me to a person in CMS. He takes my complaint and sends Humana a complaint in my name. My question is why is this problem continuing since 2007? Why has Humana continued to refuse to actually fix what would seem an easy problem to fix? Is the part of their apparent reputation of not paying claims? But, most importantly, what else can I do? I know I have more than one question here but I am so frustrated! I have a small solo practice and I personally handle my own claims. I plan on quitting Humana but I want my money first. Sorry to run on. Thank you.
ANSWER: This is really outside of my expertise, since the regulations are different than in Louisiana than they are in my state.. You might contact the SHIP program in your State at 1-800-259-5201 and request to speak with a counselor who is an expert in Advantage plan appeals.You will get their nearest office, and they will know any special regulations for that State.
Around here we have a special number for most of the the plans so we can call a specific person in the plan. I do not know if that is true in all the
states, but they may have the same setup.
The Advantage plans have to give the client a packet of information containing what is referred to as a Certificate of coverage. When the person gets a denial they should follow the appeal process outlined in that packet, and if it is still denied go another step forward with the process. The plans rely on the patients not knowing how to properly appeal. Usually rather than keep getting time lost fighting appeals, they pay.
Sorry I could not be of much help.
John
---------- FOLLOW-UP ----------
QUESTION: That is okay. I have contact the SHIPP office in Louisiana and they referred me to a specialist in Medicare.
It sounds like you are saying that it is the responsibility of the consumer, my client, to ultimately get these claims paid? As the provider, I thought it was my responsibility.
Answer
Hi Leigh
As usual, there are no hard and fast lines as to who is responsible for claim payment.
The provider is responsible for knowing what is covered. which code to use. and informing the patient when something will not be covered, and submitting the claim to the right place.
The patient is responsible for appealing any claim denials.
They have to work together when there is a problem.In this case Humana is not following the proper regulations. That is where human failure comes in. Thy do not report fraud and abuse like they should. For providers it is found in the CMS Providers Manual, For the bennie it is on the back of the Summary Notice they get. When CMS gets enough complaints, they sanction the insurance plan like Humana.
We appreciate people like you who try hard to get it straightened out.
John
Posted by
zhengyun jin
am i qualified
Question
I am only 19 years old but i have been out of work for 10 months. at the beginning of last year i was diagnosed with PCOS (poly-cystic ovarian syndrome) and i had an abnormal pap in April i was supposed to go back in Oct but i had no insurance and have not been able to find anywhere to help me... and my grandma died of ovarian cancer. So i was wondering if i would qualify for medicaid?
Answer
Hi Stephanie!
Medicaid is state specific meaning every state can have different guidelines.
Most states have an on line application. Do a search for Medicaid in (then list your state) to get to your website and see if they have an application. They also usually have simple questions that you can answer on line to whether or not you are eligible.
Sounds to me you are.
Good Luck!
Tricia
I am only 19 years old but i have been out of work for 10 months. at the beginning of last year i was diagnosed with PCOS (poly-cystic ovarian syndrome) and i had an abnormal pap in April i was supposed to go back in Oct but i had no insurance and have not been able to find anywhere to help me... and my grandma died of ovarian cancer. So i was wondering if i would qualify for medicaid?
Answer
Hi Stephanie!
Medicaid is state specific meaning every state can have different guidelines.
Most states have an on line application. Do a search for Medicaid in (then list your state) to get to your website and see if they have an application. They also usually have simple questions that you can answer on line to whether or not you are eligible.
Sounds to me you are.
Good Luck!
Tricia
Posted by
zhengyun jin
response to missing info
Question
I had physical therapy (PT) services 2 years ago in Florida. I was referred properly. I have Medicare and a Medicare Advantage HMO plan (Preferred) which covered most, if not all, of these services. However, the PT never billed my insurance correctly and did not get paid. Do you know the florida statute/law (or is it federal?) which states that the PT cannot charge me over what my HMO plan would have paid had they billed the HMO in a competent manner? I need to be able to reference the law in a courtroom. Thanks!!
Answer
Hi Jim
Call 1-800-Medicare. When it opens up, you will be in the auto section so immediately say AGENT. You will be transferred to the customer representative section. When they answer tell them you want to speak to a claims expert. When you finally get that person, explain the situation and make your request for a letter.
Do not call on Monday or early in the morning, or you will be on the phone all day listening to music.
John
I had physical therapy (PT) services 2 years ago in Florida. I was referred properly. I have Medicare and a Medicare Advantage HMO plan (Preferred) which covered most, if not all, of these services. However, the PT never billed my insurance correctly and did not get paid. Do you know the florida statute/law (or is it federal?) which states that the PT cannot charge me over what my HMO plan would have paid had they billed the HMO in a competent manner? I need to be able to reference the law in a courtroom. Thanks!!
Answer
Hi Jim
Call 1-800-Medicare. When it opens up, you will be in the auto section so immediately say AGENT. You will be transferred to the customer representative section. When they answer tell them you want to speak to a claims expert. When you finally get that person, explain the situation and make your request for a letter.
Do not call on Monday or early in the morning, or you will be on the phone all day listening to music.
John
Posted by
zhengyun jin
response to missing info
Question
QUESTION: I had physical therapy (PT) services 2 years ago in Florida. I was referred properly. I have Medicare and a Medicare Advantage HMO plan (Preferred) which covered most, if not all, of these services. However, the PT never billed my insurance correctly and did not get paid. Do you know the florida statute/law (or is it federal?) which states that the PT cannot charge me over what my HMO plan would have paid had they billed the HMO in a competent manner? I need to be able to reference the law in a courtroom. Thanks!!
ANSWER: Hi Jim
Call 1-800-Medicare. When it opens up, you will be in the auto section so immediately say AGENT. You will be transferred to the customer representative section. When they answer tell them you want to speak to a claims expert. When you finally get that person, explain the situation and make your request for a letter.
Do not call on Monday or early in the morning, or you will be on the phone all day listening to music.
John
---------- FOLLOW-UP ----------
QUESTION: I don't understand the response. It sounded like an answer was imminent if you knew the missing info. Is there no statute or law that you could refer to in order to assist me? Calling 1-800-Medicare does not help me at all. I just need a statute or law to refer to. Is there something you could throw out at me? Please!!
Answer
Jim
I am not a lawyer and can not give you legal advice.
The path to a claims expert that I gave you is the regional office to CMS(MEDICARE) It is their office that enforces the regulations for this area. Providers and Medicare Advantage plans answers to them,
John
QUESTION: I had physical therapy (PT) services 2 years ago in Florida. I was referred properly. I have Medicare and a Medicare Advantage HMO plan (Preferred) which covered most, if not all, of these services. However, the PT never billed my insurance correctly and did not get paid. Do you know the florida statute/law (or is it federal?) which states that the PT cannot charge me over what my HMO plan would have paid had they billed the HMO in a competent manner? I need to be able to reference the law in a courtroom. Thanks!!
ANSWER: Hi Jim
Call 1-800-Medicare. When it opens up, you will be in the auto section so immediately say AGENT. You will be transferred to the customer representative section. When they answer tell them you want to speak to a claims expert. When you finally get that person, explain the situation and make your request for a letter.
Do not call on Monday or early in the morning, or you will be on the phone all day listening to music.
John
---------- FOLLOW-UP ----------
QUESTION: I don't understand the response. It sounded like an answer was imminent if you knew the missing info. Is there no statute or law that you could refer to in order to assist me? Calling 1-800-Medicare does not help me at all. I just need a statute or law to refer to. Is there something you could throw out at me? Please!!
Answer
Jim
I am not a lawyer and can not give you legal advice.
The path to a claims expert that I gave you is the regional office to CMS(MEDICARE) It is their office that enforces the regulations for this area. Providers and Medicare Advantage plans answers to them,
John
Posted by
zhengyun jin
Breast Reduction
Question
Hi! I was wondering why Medicare/Medicaid denied my request for breast reduction. I have severe back and neck pain, marks on my shoulders from the bra strap, and rash in between and under my breasts. Please help me out with this!!
Thanks
Answer
I have no idea. There is no authorization needed for this unless you are in a Medicare Advantage Program. It really has to do with how the physician presents it, If you are not in an HMO, Medicare does not require an authorization and will pay if it is medically necessary.
Hi! I was wondering why Medicare/Medicaid denied my request for breast reduction. I have severe back and neck pain, marks on my shoulders from the bra strap, and rash in between and under my breasts. Please help me out with this!!
Thanks
Answer
I have no idea. There is no authorization needed for this unless you are in a Medicare Advantage Program. It really has to do with how the physician presents it, If you are not in an HMO, Medicare does not require an authorization and will pay if it is medically necessary.
Posted by
zhengyun jin
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