VIEWS: 21 PAGES: 6 POSTED ON: 9/11/2011
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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