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. 


Blogger dog-inheaven said...

I do not believe the current administration state or federal gives a flying notion about the mentally ill in this country. Nor do I believe they care about the elderly or children going to bed at night hungry/ill, about people graduating from college with no means to pay back back student loans because they are unemployed while wealthy banks who generate millions in profit pay no taxes, about horses and wolves being slaughtered and millions of dogs/cats being gassed in NC shelters or climate change which is killing us all. I think the President was bought early on and learned really well how to shake his head up and down. It doesn't surprise me about Medicare/Medicaid nor am I surprised the Governor is seriously going to close down three ADATCs and seven correctional centers including two for violent, mentally ill substance abusing adolescents. It has all become a lie, more illusions perpetrated by a privileged class to keep in place... the hungry, destitute, desperate, depressed, anxious, mentally and medically ill masses. The scariest part is that we have the truly indifferent psychotic piranhas of souls managing it all...the trinity of corporate, government and religion speaking with one scathing voice condemning monstrous global suffering for those who have no voice.

9:13 AM  

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