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
