Humana Roundtable Issues.xls by xiaoshuogu

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									                                    Issue                                 Practice   Contact    Phone       Email       Humana Response at
#                                                                                                                            2.10.11 Mtg
   We are a radiology group presently out-of-network with Humana.        Radiological Lisa     581-1500 llcarr01@l Using shared savings
    (Our contract expired 6/30/2010 due to failed negotiations           Associates Carrico    x16      ouisville.e discounts, member only
                                                                         PSC                            du          responsible for
   between Humana and University Physicians Associates.) We                                                         deductible/coinsurance vs.
   are finding claims being processed by Humana as out-of-                                                          billed charges.
   network (per Humana) but Humana is not allowing our full
   charge. The amounts listed as allowed are the only amounts the
   patient is shown responsible on the explanation of benefits when
   services are applied to deductible or when coinsurance amounts
1a are calculated.
   When reviewing an on-line explanation of benefits, you cannot         Radiological Lisa     581-1500 llcarr01@l Provider can ask for a
   tell if Humana is using a wrap-around plan or some other              Associates Carrico    x16      ouisville.e supervisor if not satisfied
                                                                         PSC                            du          with the response of
   network to discount the claim. Even the claim representatives                                                    customer service rep or
   cannot answer your questions regarding other networks Humana                                                     utilize humana.com or
   may be utilizing to process the claims.                                                                          availity.com.
1b
   Can Humana be more specific on out-of-network claims when             Radiological Lisa     581-1500 llcarr01@l RA's/EOB's are national in
   utilizing other network such as USA-MCO, NPPN, DCA, etc.?             Associates Carrico    x16      ouisville.e scope, unable to utilize
                                                                         PSC                            du          market specific language.
   This creates a lot of phone calls to their claims reps to get
   answers on why the claim was processed with disallows when
1c
   providers are non-par with Humana directly.
   It would help if the on-line or downloaded remittances gave           Radiological Lisa     581-1500 llcarr01@l N/A
   equal information to remittances printed and sent with paper          Associates Carrico    x16      ouisville.e
                                                                         PSC                            du
   checks. The information should be the same no matter what
   format you are reviewing it under.
1d
     Practice received a letter from Humana stating they no longer       Carl        Stacey    713-4992 coppolado     Per ON op notes no longer
     have to send op notes but they are still receiving denials for op   Coppola,    Cline              rmanpsc       needed. Humana still had
                                                                         MD                             @bellsout     provider flagged as op notes
     notes needed. Orthonet is the one asking for op notes and they                                     h.net         required, Humana removed
     do not seem to be on the same page as Humana.                                                                    flag; this issue should be
 2
                                                                                                                      resolved.
    Humana Medicare PT claims processing problems began in         Louisville Melanie   897-1844 melh@lou Humana has an automated
    October, 2010. These claims are filed exactly as Medicare PT   Orthopedic Hendricks          ortho.com process that processes
                                                                   Clinic                                  claims against NCDs/LCDs;
    claims but are being denied stating LCD or NCD issues. This is                                         Medicare does not, theirs is
    incorrect because Medicare is processing without any problems.                                         a manual process. Just
    Humana cannot seem to resolve this issue.                                                              because Medicare doesn't
                                                                                                                       deny a claim for NCD/LCD
                                                                                                                       doesn't mean it followed the
                                                                                                                       NCD/LCD logic and should
                                                                                                                       have been paid.
3
    MRIs are pre-authorized with chart documentation. The claim is        Louisville  Melanie    897-1844 melh@lou Provider obtains auth with
    paid. Many months later, payments are recouped stating the            Orthopedic  Hendricks           ortho.com inaccurate information,
                                                                          Clinic                                    medical records are
    procedure was not medically necessary. Why then is it pre-                                                      compared to the clinical
    authorized based on the same date?                                                                              inforamtion provided at the
                                                                                                                    time of authorization, if the
                                                                                                                    medical records don't
                                                                                                                    support information given,
4                                                                                                                   service may be recouped.
    As an anesthesia provider, Medicare requires us to split our bill     Anesthesiol Judy Blain 458-7400 judyblain Adjuster error; adjuster has
    between the Anesthesiologist and Certified Registered Nurse           ogy Assoc                       @iglou.co been coached on correct
                                                                          PSC                             m         processing of claims.
    Anesthetist (CRNA). When Medicare crosses over these claims
    to Humana, they tend to pay one provider but not the other
    denying as a duplicate. There is no rhyme or reason to which
    provider is paid. It requires us to then call Humana to explain
    split billing to them and then they reprocess the incorrectly
    denied claim for payment. How can we resolve this issue once
    and for all so that our staff time is not spent explaining the same
    situation over and over again to get the claim paid appropriately?
5
  Waiver/Humana-UL contract issues:            a.    Not paying        University   Patti     583-7377 pasacr01 Waivers are approved by
  claims with waivers at in-network rate; b. Some people at            Pediatric    Sacra              @louisvill physician not group.
                                                                       Surgery                         e.edu      Waivers are approved on a
  Humana are refusing to issue a waiver under our group name.          Assoc                                      case-by-case basis for 30-
  They will only issue one under a specific doctor, which poses a                                                 60 day timeframe.
  problem if the patient reschedules to a different doctor.; c.
  Some of the waivers are only good for 1-2 months, which is a
  problem, especially when they have a patient that has to be
  scheduled for testing and it could take several months worth of
  follow ups.; d. Parents have cancelled their child’s surgery
  due to the Humana/UL contract issues and have been waiting
6 since July, 2010 for the contract to be met so their child may
  have their surgery close to home.; e. Humana 3rd party the
  Taking discount on in-network claims through staff tells             University   Patti     583-7377 pasacr01 Yes that is correct.
                                                                       Pediatric    Sacra              @louisvill
     administrator, but paying claim as out-of-network                 Surgery                         e.edu
7                                                                      Assoc
     When sending checks for claims to patient for claims payment,     University   Nicki B   583-6233 nickib@un     Provider receives letter
     no remittance advice is sent to us describing exactly how the     Pediatric                       iversitype    which contains claim #,
                                                                       Surgery                         diatricsurg   member name, member ID
     claim should be paid and to send to the secondary insurer.        Assoc                           eryassoc.     & DOS. Provider can get
                                                                                                       com           payment information from
                                                                                                                     the member, Humana.com
8                                                                                                                    or availity.com.
  Humana telling the patient that the practice billed something        University   Nicki B   583-6233 nickib@un     Can request a supervisor if
  such as place of service incorrectly.Information is entered on the   Pediatric                       iversitype    CSR is not giving out
                                                                       Surgery                         diatricsurg   accurate information or
  claim correctly and the remittance showing a completely              Assoc                           eryassoc.     utilize humana.com or
9 different denial.                                                                                    com           availity.com.
  Humana pending claims with no explanation and when the               University   Donna B   583-6233 dbro126@      There is always a reason
  practice calls, they still cannot provide an answer and state that   Pediatric                       yahoo.co      when claims are pended
                                                                       Surgery                         m             (COB, medical records,
  they will let the team leader figure out the problem.                Assoc                                         etc.). Can request a
                                                                                                                     supervisor if CSR is not
                                                                                                                     giving out accurate
                                                                                                                     information or utilize
                                                                                                                     humana.com or availity
10                                                                                                                   .com.
     Why can’t practices call Provider Reps for Humana?                Deer Park   Sherry      451-5955 fms05@in Humana has local Contract
                                                                       Fam Drs     Mattingly            sightbb.co Reps for any contract
                                                                                                        m          related questions. There is a
                                                                                                                   Centralized Provider
                                                                                                                   Relations Unit for any
                                                                                                                   claims/authorization/service
                                                                                                                   questions.
11
     Can Humana set up a fax line for additional information requests Deer Park    Sherry      451-5955 fms05@in The process for submitting
     to be sent back?                                                 Fam Drs      Mattingly            sightbb.co additional information is
                                                                                                        m          outlined in the letter, if
                                                                                                                   faxing is an option the letter
12                                                                                                                 would state that.
   When calling the phone number on the patient card, the practice     Advance     Danielle    893-0159            Inappropriate transfer by
   is re-routed to a different number after giving all of the          ENT &       Graham                          CSR, CSR has been
                                                                       Allergy                                     coached.
   information for the inquiry. This process for one patient takes
   from 26-45 minutes. EXAMPLE:Phone: 877-857-7551; called
   this number and gave ALL information – transferred to 877-616-
   8798. Gave all information again. Transferred back to original
   number and gave ALL information again. Transferred back to
   877-616-8798. Had to give ALL information again. Then finally
   transferred to 866-427-7478. Had to give ALL information
   again. Talked to Jillian and found that this particular Ford plan
   member was handled at 866-427-7478. Ref: 724815124108. 29
13 minute phone call.
   Delayed allergy testing (95028) denials stating “Professional       Advance     Danielle    893-0159              Allergy testing benefit
   interpretation charge not allowed separately on automated lab       ENT &       Graham                            loaded as covered when
                                                                       Allergy                                       performed in an office
   tests. Upon appeal, claim denied stating “Not appropriate for                                                     setting vs. other places of
   provider to bill TC only in an inpatient or outpatient place of                                                   treatment.
   service. TC should be billed by facility where procedure is
   performed.” The CPT definition of 95028 is as follows; 95028 -
   Intracutaneous (intradermal) tests with allergenic extracts,
   delayed type reaction, including reading, specify number of
   tests. The denial remarks above do not make sense with this
14 code.
     Humana is not paying the new CPT administration codes             East         Diane       721-0012 dmyers@ System corrected 2-12-11,
     properly (90460 & 90461)…i.e. sometimes they do and               Louisville   Myers                eastlouisvi all affected claims will be
                                                                       Pediatrics                        llepediatri reprocessed.
     sometimes they do not. These codes went into effect                                                 cs.com
     1/1/11. For vaccines with more than one component, we are
     supposed to use 90460 for the first component and 90461 for
     EACH additional component when counseling for each
     component is provided.
15
   I know this may be late to submit but a question I have for the              Linda                      Lwoods@ Coverage may be under a
   Humana reps would be –Do any of your Medical plans have                      Woods                      kseyewor vision rider when performed
                                                                                                           ks.com   by an optometrist.
   routine vision coverage through the medical plan, not through
   their separate vision plan, not done as a screening at their PCP
   office but with an ophthalmologist? We have people come in for
   routine eye exams and we call or check the website and are told
   the patient gets one routine eye exam a year through the
   medical plan but after filing EOB says “no routine vision
   coverage.” I am even having trouble with these vision claims
   themselves. We file numerous times and are told they never
   received as though they just discard the routine eye exam
   claims even though someone at Humana has told us they have
16 vision coverage at time of appointment.                           Kenneth R Smith’s office
   I am having issues with Humana Advantage claims for Avastin                  Roxanne                    royler@ey Process requires submitting
   J3590 getting denied for invalid modifier use. Medicare                      Oyler                      ecenters.c notes to support codes
                                                                                                           om         billed.
   guidelines Article A46095 (LCD L25820) specifically state to
   report RT or LT with the J3590. When I have called the claims
   dept. I am told to submit notes supporting the coding. When I
   have offered the article number that Humana can reference I am
   told that I must submit or fax the supporting information. I have
   5 claims received today denied with this situation. My call
   reference number today for patient ID H07931387 for date of
   service 9/1/2010 is 780678555809.
17
   I was just on the other end of trying to get a waiver (for me) to see my East         Diane   Waivers can be requested
   GI who is a UL physician. After spending 40+ minutes on the phone (2 Louisville       Myers   by either the member or the
                                                                            Pediatrics           provider. The clinical team
   transfers) I was transferred to the phone number I gave Humana for a                          needs certain information in
   direct contact at Dr. McClave’s office. Laura at UL was very nice and                         order to process the waiver
   said she would do what she could to get the waiver. All together, I                           request, understand there
   spent over 1 ½ hours making an appointment and TRYING                                         may be information the
                                                                                                 member may not have, will
   unsuccessfully to obtain a waiver for an office visit. This is
                                                                                                 follow-up with the clinical
   unacceptable. Humana asked me questions including what the                                    team to see if they can
   physician’s tax ID number was. I doubt that many/any patients have                            obtain the information from
   their physician’s tax ID#. I understand that Humana would rather not                          another source.
   approve waivers, but the time involved to get one is unreasonable. I
   now also understand why our office, and other physician offices are
   requesting their patients to initiate the waiver. I do not have enough
   personnel to spend 1 ½ hours making a specialist appointment and
   attempting to get a waiver. We will definitely reconsider our options
18 when East Louisville Pediatrics’ Humana renewal comes due.

								
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