Thursday, March 28, 2013

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

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? 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'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.

Sunday, March 10, 2013

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. 


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........."