Avoid Humana's PPO Choice Plans: Humana's Failure as an Insurer of Medicare 'Advantage' Patients

Marsha V. Hammond, PhD
Clinical / Health Psychology
NC Licensed Psychologist
cell: 828 772 5197
e mail: chomskysright@gmail.com

 

To: Cornell Tilghman, Investigations, CMS (Centers for Medicare/ Medicaid Services)

 

Date: April 26, 2013

 

RE: Humana PPO Choice Insured clients of mine & change of Humana policy without notification

 

Dear Mr. Tilghman (410 786 1047; cornell.tilghman@cms.hhs.gov)

 

As per our phone conversation and at your request, I am outlining, grossly, the extreme difficulties I have experienced over the past couple months in working w/ Humana. 

 

I have spent over 5 hours trying to get to a solution; my client has spent over 9 hours trying to get to a solution----so that she can continue to see me, a Medicare provider, who is out of network vis a vis Humana.  This has never been an issue until 1.1.2013 whereupon they discontinued payment to me; sent me no explanation of what was going on----re: my Humana PPO Choice insured clients .   This is not true re: my other Humana PPO clients-----at least so far. 

 

I have worked w/ these same clients on and off for years.  There is nothing that they have changed about their policies.  Humana has changed the contract for their insured such that they now must meet a $500 deductible for out of network providers.  However, prior to 1.1.2013, it did not matter that I was 'out of network' as Humana, as you know, is a Medicare 'Advantage' company---an oxymoron if there ever was one.

I encourage all of my clients to remain on Medicare, not any Medicare 'Advantage' plan.

 

These are disabled clients and the reason they have chosen Humana's PPO Choice, I believe, is that that allows Medicaid to PAY for their Humana premium.  These are people who live at the poverty level and they cannot afford a $500 deductible.  Humana personnel indicate that the $500 deductible is for both medical and behavioral health (with which I am concerned) but then why have their physicians not billed them?  Again and again, after speaking to over 15 Humana personnel, I get passed around, from Provider Relations to Contracting to Licensing and then back to Provider Relations. Thus THERE APPEARS TO BE NO PARITY RE: BEHAVIORAL HEALTH AND PHYSICAL HEALTH. That is my first question.

 

I have spoken to the NC Department of Insurance about this.  They were no help; I went quite high in that government organization to have the supervisor simply tell me I had to be 'In Network' when prior to 1.1.2013, that was not an issue.  As I said, I have received no information from the various discoordinated arms of Humana about this issue, leaving my clients in the lurch.

 

To be more specific, today I spoke to Kay (no last name) @ 866 376 2921 x 7598724.  She told me that I would be paid back to a January 8th, 2013, session for one of their Humana PPO Choice insured.  In other words, the out patient behavioral health sessions would be paid retroactively.  Then a woman named Angelique @ 1 800 491 4421 called me and told me that whether I was to be paid or not was 'up to medical review.' 

 

So, after 15 hours of combined phone calling to Humana, neither the client or I understands whether she can continue to see me as I cannot work for free. 

 

Can you please help with this? At this point in time, I am re-testifying my CAQH credential which Kay indicated is part of the 'in network' credentialing process.  Humana has the other information associated with my license. 

 

How is it that Humana can change their policy without notifying providers.  How can they pretend to be a Medicare 'Advantage' company? They should instead identify themselves as NON MEDICARE which would make it clear that they are no longer linked to Medicare as in the past vis a vis this oxymoronic 'Medicare Advantage' descriptor which they have to tauted in order to lure consumers into throwing out their regular Medicare and changing to Humana.

 

As far as I am concerned, they have committed 'baiting and switching' re: these PPO Choice clients (Medicare utilizes a $200/ year deductible, I believe) and I believe that someone should call them on the carpet for this behavior which is unacceptable.  If they are a Medicare 'Advantage' company then why don't they have the same Medicare deductible?  If they are a Medicare 'Advantage' company, then why isn't my long-term status as a Medicare provider acceptable to them---all of a sudden?

 

Please pass this e mail to anyone you like. It is also posted on my blog which concerns itself since 2007 with NC mental health reform---which is in shambles. 

McCrory's Medicaid Manifesto: Privatize Medicaid : Going from Very Bad to Way Worse

What's wrong with this picture, dear Waldo?  Can we even find Waldo or any of the recipients of Medicaid in this picture promoted by Republican Governor McCrory which is aiming for capitated Medicaid?  What does that mean?  That means that any of the services that cost to much will be thrown overboard.  Will it be much harder to launch an appeal process re: these private companies being proposed.  As dear Sara would say, You betcha. 

That means (just like living in current Syria where city by city they blow each other up) that we're headed for another blow-up of Medicaid.  I speak to this matter as associated with being a solo doctoral level psychologist who has seen hundreds of Medicare/ Medicaid clients over the past 10 years. 

Where have we been since 2002 re: NC Mental Health Reform---and by default---Medicaid reform?

1. In the beginning, prior to mental health reform and as it came on board, we had community mental health centers which were well known in the community as a place to turn to. They provided mental health services which was paid for at the state level by DHHS.  In western NC they were commonly and simply known as "Smoky" and "Western Highlands."

2. Mental health reform begins in 2002, starting in the most western part of NC...FAR away from Raleigh.  Smoky Mtn Center LME and Western Highlands Network LME which have a combined 25% of NC's 100 counties were set up.  At first, they were handling only state funded clients or IPRS clients.  REMEMBER: part of the reason for mental health  reform was that everyone be able to access mental health services.  This was a nightmare until certain companies were the only ones who took the state funded clients, for the most part.  So, these companies, such as Meridian Behavioral Health Services in Waynesville, NC, saw a lot of these people.  Private providers such as myself threw in the towel re the paperwork.  

A few years into this process a large company under WHN LME went belly up, which was carrying 10,000 insured people.   The LME's were NOT handling Medicaid.  God knows how much money was wasted re: administration re: these LME's and their administration of just state funded clients.  Paperwork flew. 

Meantime, Medicaid providers such as myself worked efficiently re: obtaining authorizations for treatment which was done by Value Options; payments were processed very efficiently by Hewlett-Packard (some subsidiary of that company) e.g., HP Enterprises on my Medicaid Explanation of Benefits.  I was given written or easily obtained EOB information so I could see if I had screwed up in my billing.  Worked well.
 
3. Then, over the past year or two, the LME's began 'managing' Medicaid.  What has happened? I had to get 're-credentialed' as a Medicaid provider even tho I had been one for years.  This was 20 plus pages paperwork for each LME.  It took WHN LME over one year to do this and then I was given only an out-of-network status just for being a pain in the ass.  SMC LME moved things along efficiently.  Guess who's going down? WHN LME.  So, apparently SMC LME will gobble up WHN LME in some manner.  I hope so. 

RE: the running of my business, I get no Explanation of Benefits.  I have no idea if I am being paid correctly by either LME.  In face, I haven't heard from SMC LME since I advised them upon their letter to me that they wanted to come around and 'inspect' my office to which I replied: "I don't have an office...I see my clients in their homes...you are welcome to ride around w/ me in my car if you want." 

I have to pay double for my biller to launch first to Medicare (always the primary payor) then fax to her my EOB's from Medicare so that she can then bill Medicaid.  This was AUTOMATIC prior to the LME's managing Medicaid.  So, more costs for the provider/ more paperwork = less patient care and providers running away from Medicaid. 

4. McCrory's Medicaid Manifesto: capitalization of Medicaid services.  With each step of removing the hand-on treatment of Medicaid recipients in the community (remember, they used to be fondly called "Smoky" and "Western Highlands") the insured is an additional step removed from having any control at all over their services. Of course, this is the point. 

Where does this leave me, unless I do another round of "re-credentialing" with one of these undoubtedly crummy private companies who view psychotherapy as expendable, expensive, and mostly useless?

Running away from Medicaid. 

                            ********************************

"Our goal is to shrink government to the size where we can drown it in a bathtub."

Grover Norquist (Republican)

                     ***************************************************

Read more at http://www.brainyquote.com/quotes/authors/g/grover_norquist.html#k3PcQ06rAk2eu3b0.99 http://www.journalnow.com/news/state_region/article_ea55e058-9cc4-11e2-b634-001a4bcf6878.html

"....Governor Pat McCrory wants to pay a handful of statewide managed-care providers to deliver medical, mental and dental care to the elderly and disabled.

The McCrory administration’s concept is that three or four companies would be selected through an open bidding process. Each would set up networks of medical providers. They would be paid a set monthly amount for each Medicaid patient enrolled, with increases for those groups that have sicker patients and for inflation. Their contracts with the state would require them to focus on patient outcomes rather than paying for each test or procedure, Wos said.

The managed-care operators will be “responsible for the outcomes and for managing their own risk so the taxpayer will no longer be on the hook for all of the overruns,” said Wos, a retired physician.

The changes will require approval from the federal government and action by the state’s General Assembly to meet a July 2015 target for the revamped Medicaid program. About 70 percent of the country’s Medicaid enrollees are served through managed care systems that pay providers a monthly rate, according to the U.S. Centers for Medicare & Medicaid Services.
The trade association for the state’s physicians said it was worried that McCrory’s proposal would attract corporations whose main goal was delivering shareholder profits.

“If the administration’s idea of reform is bringing in out-of-state corporations so they can profit by limiting North Carolina patients’ access to health care and cutting critical medical services to our state’s most vulnerable citizens, that is not change we can support,” N.C. Medical Society CEO Robert Seligson said in a statement."

Humana: Left Hand has no idea what the Right Hand is doing : LifeSync Managing Humana Mental Health in the Dark

Oh, did I mention that we need a ONE Payor system and it needs to be Medicare?

So, another Humana client of mine called Human and they went, "Duh"...we don't know what the problem is.  He was directed to call LifeSync, a company in Dallas, TX that manages the mental health/ behavioral health for Humana.  Client talked to 'Layla' at extension 1028921; tel number 866 376 2921.  I called her and left a message.

Client was informed that as far as LifeSync knows, there is no issue re: PPO clients and unlike other Humana client who was advised that I was going to receive a 'Waiver' for her to continue seeing me, LifeSync said they had never heard of anything like that.

So, you got a huge company who is completely dysfunctional.

I'm a psychologist: I'm glad to offer you my services so you can understand the impact that your dysfunction has upon your providers and your insured.

Asking Center for Medicare & Medicaid Services Administrative Offices to Tackle lack of Mental Health Care for Humana's Insured

e mail letter sent to Administrative Offices of CMS w/ cc to Senator Hagen (liason: Anna Abram) and Senator Burr (liason: Karen Wade) re: (obvious) change in contract between Humana and CMS regarding mental health care/ Part B for NC citizens w/ mental health needs

".........Specifically, this is the problem: Humana, a Medicare Advantage
company, whose clients I have been seeing and reimbursed for
seeing----for years----has apparently, without notice, changed its PPO
policy such that I can no longer provide services to their clients.  I
have seen Humana PPO clients for the past five years.

The company managing Medicare in NC is Palmetto.  They have no information.
Humana has no information except to say that I now have to be
"In-Network" whileas before by being a Medicare Provider of many
years, I was able to work w/ this Medicare Advantage company.
Palmetto personnel indicated that the Part B's of these companies,
such as Humana and United Health Care (had the same problem last year
regarding one of their insured) are largely unregulated.

The NC Insurance Commissioners Office was not helpful.  They believe
that I am supposed to be an In-Network provider and they had no
information about how to deal w/ this matter. Again, Humana will not
allow me to become an In-Network provider.

***Does this not violate some part of the contract which must have
been recently changed vis a vis CMS and Humana?***

Why doesn't the NC Insurance Commissioner's office not guide citizens
with mental health concerns to avoid the Medicare Advantage companies
given the company's Part B unhelpful changes?

How is it that citizens who have mental health challenges are
challenged to come up with solutions that citizens with medical
illnesses as associated with Part A Medicare ----are never required to
address? There is supposed to be mental health parity.  There is no
parity.

Thank you for your response.

Marsha V. Hammond, PhD  NPI 1194700591Clinical / Health Psychology

Playing Footsie w/ Humana, a Medicare 'Advantage' Company Who No Longer Pays Mental Health Providers: Call 1 800 457 4708 to Get a WAIVER

Is there an alternative universe I can rocket over to?....one without Medicare 'Advantage' (MA in the vernacular of the Medicare Palmetto person----company which manages REAL Medicare for NC) companies? Someone pinch me.  Will no one rid us of these troublesome Medicare 'Advantage' companies?

Here is what I did today re: several Humana clients.  Let's do a little review.  Under George Bush, Medicare was allowed to 'expand' to allow privatization of Medicare.  That allowed companies like Humana, United Health Care, etc., to PRETEND to offer Medicare services. 

What made people fall for this? They offered perks like paying for people's Medicaid; the other day a Humana client showed me his 3 'free' bottles of medication that Humana sent to him.  Free! That client also has a 'nurse' who  calls and checks on him re: his consumer satisfaction.  Medicare doesn't do this.  Medicare is busy running efficiently. 

Oh, did I say that we need a one payor system and that needs to be Medicare----so we don't go broke while the CEO's of these companies jet off to the Cayman Islands?

These Medicare 'Advantage' companies (oxymoronic, if there ever was such an appropriate descriptor) ply people with perks and promises which are now being downsized due to the Obama adminstration having a bit of a problem with the fact that the efficiently functioning Medicare (5% administrative overhead) has been using its money to pay for the padding of private pockets (18% adminitrative overhead for these MA companies).  Aw, gee, now here come the cuts and where do you think they start: with mental health, silly.

Here is what took place today, as I drove around in my car (if I had to sit and do this I could never earn any money) calling Humana and also the NC Insurance Commissioner's Office.  Mr. Wayne Godwin, Insurance Commissioner: hire some more knowledgeable people please.

Around 12 noon: yesterday Humana client gave to me his EOB (Explanation of Benefits) which revealed that for January, 2013, I was to be paid $34.83 for 5 individual therapy sessions.  This would normally pay me about $350, more or less.  I go to his home; this PhD provides individual therapy for over and hour and for the past 4 years Humana has paid me.

I ask my biller what she knows.  All she does is submit codes I put into place.  Bear in mind that all the CPT codes changed 1.1.2013.  This has very little to do w/ what has taken place.  I wonder: is is the CPT codes.  NAW.

Apparently Humana (who knows who else?) has driven thru CMS (Centers for Medicare/ Medicaid Services: federal: tel: 1 800 633 4227: I haven't called them yet; they're in Bethesda) a slimmed down contract such that Part B (MENTAL HEALTH) Medicare providers can be drilled into the ground.  That's my speculation but I have yet to substantiate that and who knows how many levels of CMS I have to go thru to get that answer. 

The client's EOB indicates the error code "OMR: This amount billed exceeds normal amount of charges for this type of service. You are responsible for excess charges."  My client wants to know if he owes me $500.  Well of course not. 

Silly you.  You think the error code has real meaning?  I call Humana.  I start off w 1 800 457 4708 associated with claims.  I talk to Jenny.  ACKK.  She knows nothing.  Hand me the supervisor.  I talk to Drey. ACKK.  He knows less.  I talk to Brenda.  Get disconnected. 

I go over the NC Insurance Commissioner's Office, the SCHIPP program which is supposed to know something about how NC citizens get manhandled by these companies . I get a woman who knows nothing.  I call back.  I get Woody who knows that "we really advise people to steer away from the HMO's of these private companies."  I don't know if the client has a PPO or an HMO Humana account.  I call the client.  Client has a PPO.  Should not be a problem.  I call back to Woody; get a voice message; leave a message.  I get tossed up to supervisor as Woody has told me everything he knows (plus Joe told me the same), Josephine, the supervisor, proceeds to tell me that 'you have to be in-network as a provider for Humana to pay you.'  This is news as they've been paying me for years as a Medicare provider.  REMEMBER: this is a Medicare 'Advantage' company: they have all the trappings of Medicare.  This 'you must be 'In-Network' is what Humana has told me as I yammer away and tell them then why was I paid $34.83 for the 5 individual therapy sessions and why have I been paid FOR YEARS for seeing Humana clients until Jan, 2013.  Josephine puts me on a three way conf call with her boss to stress this point.  Makes no sense to me.  I hang up. 

I go back to Palmetto who manages NC medicare.  I get a Part B provider number, 1 877 267 2323.  This is associated w/ contractor enrollment.  'Jarod' (these people never use their real names, I'm quite sure) tells me he has no ability to interface w/ Humana, the Medicare' Advantage' company and that these private companies are unregulated.  Good luck is more or less what I get from him.  Sure, I already tried to type in the client's Humana number which of course Palmetto medicare does not recognize.... . FOR ITS NOT REALY MEDICARE. 

Somehow I get a number associated with Humana pertaining to provider services 1 866 830 3043.  I tell the guy I have several Humana clients who I continue to see and that I have been told I am now 'out of network' after all these years.  I ask to speak to Provider Relations.  He tells me he will 'send them an e mail.'  I ask can I talk to them.  He tells me they don't have an extension.  He says, upon me asking 'When will I hear back about this matter" that it will be "within the next 30 days" upon which I freak out.  I'm already potentially out of hundreds of dollars from continuing to see my Humana clients, assuming I will continue to be paid to do what I have been doing for years. 

He mentions that there is a WAIVER THAT CAN BE UTILIZED in order for a formerly in-network (apparently) provider and THAT THE NUMBER FOR THE WAIVER FOR THE CLIENT TO CALL IS: 1 800 457 4708. This is NOT the number that is on the back of the Humana card that the client has. 

I call one of my other Humana clients.  I ask if she will call and speak to them.  She does.  They tell her that a piece of paper will be sent to me such that this 'Waiver' will be created so I can continue to see her, something she desires to do. 

I'm waiting on that document.  I better get it or I will just create more stink.  I'm in a solo practice and so there's no one telling me to shut up....you're putting heat on us.

How many freaking telephone numbers does Humana have and why can't I talk directly to Provider Relations?

As the Palmetto REAL Medicare guy indicated: these Part B companies are unregulated. 

Then why doesn't the NC Insurance Commissioner's office tell clients that when it comes to Mental Health Care that they better return to REAL Medicare? I tell all my clients: whatever you do, do not exchange your realy medicare for a phony Medicare company.

Why does the NC Commissioner of Insurance's office dance around---like Humana----that these Medicare 'Advantage' companies SHOULD NOT BE utilized by citizens with mental health issues? 

Why indeed? Remember: the NC State Legislature has been bought and sold by BCBSNC.  They're just cousins to Humana, United Health Care.  Don't believe me? Then google up 'madame defarge BCBSNC' for the blow by blow details which have been documented since 2007.

Western Highlands Network LME GOING DOWN : SMC LME Will Take Over (& I Can Get Paid to See my Clients Finally)

Boy, I sure did my share of kicking this can down the road, informing Smoky Mountain Center of all the problems w/ WHN LME. 

The last straw for me took place several weeks ago when I received a letter in the mail that WHN LME wanted to come over and 'review my office.'  I told them I saw my clients in their homes and I was willing to take them around w/ me if they liked. 

Prior to that, it took them over a year to put my provider status into place.  Then they gave me an out of network provider status. 

I never received any kind of ridiculous request from SMC LME re: looking at my office.  My re-application (remember: we were all already Medicaid providers when all this LME business started....) w/ SMC LME went thru smoothly.

Good riddance. 

_____________________________________________________________________________
"......· http://medicaidlawnc.wordpress.com

And the mental health system spirals downward….

There is talk that Western Highlands, the Managed Care Organization (MCO) currently servicing eight Western North Carolina counties, Buncombe, Henderson, Madison, Mitchell, Polk, Rutherford, Transylvania and Yancey, will be the next casualty to the MCOs.

The MCOs, formerly called local management entities, are the regionally-based agencies that receive a set monthly payment from the state to provide both state- and Medicaid-paid services. With that money, the MCOs must allot services for everyone under their care.

Rumors at the Capitol is that Western Highlands may be swallowed up by Smoky Mountain Center, the MCO regionally adjacent to Western and servicing 15 counties.

Currently, Western Highlands has no CEO. No Chief Financial Officer. And the Chief Medical Director is near-retiring.

But the lack of leadership is not the only issue with Western.

Health care providers have complained that the majority of authorizations for new services or renewed services are being denied by Western.

The whole point of the MCO-based Medicaid system is to allow the state to dole out chunks of Medicaid funds to each MCO. Then the MCO approves services for Medicaid recipients until the money runs out.

Considering this is only the 2nd year Western Highlands has been servicing the 8 counties, it seems a bit odd to be denying so many services, if this is actually happening........."

Medicaid Waiver One Year Later: Smoky Mountain Center LME leaves Western Highlands Network LME in the Dirt re: Consumer / Provider Satisfaction

Thank you, Donna Baker Oliver, of Western Highlands Network LME, for letting me know the status of my application as a doctoral level licensed psychologist to become an Out of Network provider as associated w/ WHN LME.

Its one year later as associated when this application started. That's not even as an In Network Provider; that's as an Out of Network Provider.

It therefore appears that WHN LME has little to no interest to see that well trained providers outside of systems e.g., the little companies that dot the landscape and have QA's or lesser level trained people working there in a constant churn of turn over---- have any possibility of working within the domain of public health----even though those providers have been providing Medicaid Services for over a decade.

And yet, there are massive wait times for anyone to see a therapist or have an assessment by a well trained professional. Mental health is not like getting one's blood pressure checked, as you know. It is an 'emergent' discipline.

This is in distinct contrast to the consumer-friendly/ provider friendly Smoky Mountain Center LME.

Pass this e mail to anyone you like.

Sincerely,

Marsha V. Hammond, PhD, Licensed Psychologist, Asheville, NC

cc: David Weisner, PhD, NC Psychological Association
Brian Ingraham, CEO SMC LME
____________________________________

On Thu, Jan 3, 2013 at 8:27 AM, Donna Baker Oliver wrote:

> I have checked with our credentialing specialist and your application is currently with the credentialing committee. Thank you,

 Donna
 Donna Baker Oliver, LCSW
 Outpatient Provider Network Specialist
 1-800-671-6560 ext 2977
828-225-2785 ext 2977
(fax) 828-225-2796

Medicaid Waiver: Even Though Smoky Mountain Center LME States they Do Not Need Medicare information to Bill Medicaid, Billing Entities State the Opposite

When, if ever, will these travails every end? Will providers ever have the seamless billing BACK that they had when Medicare wrapped around to Medicaid automatically----PRIOR to this ridiculous Medicaid Waiver?  Though Smoky Mountain Center LME personnel indicate that they do not 'need' the EOB's or billing information from Medicare as 'they trust us' (the providers)-----the billing entities cannot bill SMC LME for the wrap-around Medicaid services without having the EOB's.

This is what my biller has advised me:

"....I can only produce 2nd claims electronically by putting in the primary/Medicare information on what they paid, so technically SMC does not need the physical paper EOB but do need the information to appear on the electronic submission.   My system will not produce a 2nd claim to any carrier without the primary information keyed in...."

Medicaid Waiver: More Difficulties w/ Re-credentialing at WHN LME versus Easy of Credentialing at SMC LME

Hello IT at WHN LME and Donna Baker Oliver (recredentialing of individual providers at WHN LME) :

I have talked to on the phone just now, the gentleman at IT at WHN LME.  I cannot open this link:

•Provider Evaluation Form (3/26/12) which is on this page: http://www.westernhighlands.org/provider-enrollment.html#Endorsement

You asked for a 'recomendation' from a LPA or PhD.  I know no psychologists in NC; they all ran away re: the travesty associated with NC medicaid, and in particular this Medicaid Waiver.

THEREFORE, I am utilizing two psychologists, PhD's, in GA, where I was previously licensed.

PLEASE let me know if this is a problem, Ms. Donna Baker Oliver.  Thank you for your returned call.  I am forwarding the forms to Mistie Sellars as you requested if your IT person can figure out where the form is.

In case you didn't know, the recredentialing process for SMC LME did not demand this and they quite willingly accepted the people that I regularly work with who are mental health professionals in Haywood county.

Thus, once again, WHN LME, has made this recredentialing process extremely difficult not to mention that your web link is not working.

I have had to go back and forth to the post office in order to pick up the certified letter that was originally dated October 3, 2012, simply telling me that I needed to have a Licensed Psych Associate (a master's degree person; the people that SMC LME accepted were master's degree people and a psychiatric nurse practitioner) or a PhD, such as myself.

Neither did SMC LME require me, as WHN LME did initially, to send in a copy of my 'college transcript' which is a moot point as the NC Psychology Licensing Board would not have licensed me if they had not seen that.  I, as well as any psychologist, am easily found at the NC Psychology Licensing Board.

Sincerely,
--
Marsha V. Hammond, PhD
Clinical / Health Psychology
NC Licensed Psychologist