Friday, April 26, 2013

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:
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;
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. 

Saturday, April 06, 2013

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 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)



"....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."