Humana
Rick Stapleton
Description
Collection
Title:
Humana
Creator:
Rick Stapleton
Date:
3/14/2013
Text:
Good morning Colleagues,
Here is my follow-up to the list-serve for the situation I described concerning the Humana pre-auth denial of test sockets and what we did. The responses I got from the list-serve pretty much coincide with what we had to do with this specific situation.
1. We contacted the patient to inform them of what was going on and our action plan. We told them to be aware of the denial and we may need their help to contact Humana and what may transpire (may have to sign an ABN form) in the event Humana refuses to authorize the test sockets.
2. I contacted Joe McTernan at AOPA and discussed the situation, was informed that they are supposed to provide the services according to Medicare's guidelines but they have latitude that doesn't seem to be public knowledge or in written format for what they can or can't do.
3. We called Humana back, got a different representative, and magically when we told them these are covered and have been paid for by Medicare that they are now authorized, of course we have documented who, what time, and phone number of the rep.
4. I was prepared with a copy of the LCD, my dictation that documents the medical need for the test sockets, and the reason for the new prosthesis. They did not ask or need that information as we were told the other representative was wrong.
I thank all of you for responding, there were many people who have had similar denials and took action (similar to what we did outlined above) to get things taken care of properly. Some people misread my statement and assumed that I had already delivered the prosthesis. The patient did not receive the prosthesis yet, we always call the Medicare Replacement plans give them all the Lcodes and then they tell us which ones need pre-auth (seems weird that they tell us some codes need pre-auth and some don't so we don't take any chances and call on every patient that has these type plans.) The prosthesis is replacing one that is over 5 years old, can't be modified anymore (all modifications documented and billed), and all other paperwork is complete. Because of scar tissue, very prominent distal tibia, and poor surgical results, change in health (all documented for medical necessity in the EMR), the fitting process has required the use of two (documented by our fabrication EMR) test sockets. The patient has had several health and family challenges that have delayed the delivery process by many months. We are preparing to deliver now so we wanted to make sure everything is still ok before delivery/billing. We do not separate the test sockets for billing. With the new changes in Medicare which requires a detailed prescription signed by the doctor to be in the file at the time of delivery not before billing, makes me hesitant to have to harass the doctor for two different prescriptions for one prosthesis. We are now routinely asking for physician notes for every patient that comes in for a new device and most of the physicians are very understanding so I don't want to inundate them with additional prescriptions. The patient has been informed the whole way so they understand all the garbage we put up with just to get paid (and hopefully keep our money.) We will always appeal and fight for every challenge we get and I encourage all of us to do so or we will not survive. We are such a small voice in a large forest that if we don't keep screaming no one will hear us.
Thanks again for this valuable resource,
Rick Stapleton, CPO
President
NOTE: The information in this email and any attachments may be confidential and/or medical privileged. Access to this email by anyone other than the intended addressee is unauthorized. If you are not the intended recipient (or the employee or agent responsible for delivering this information to the intended recipient), please notify the sender by reply email and immediately delete this email and any copies from your computer and/or electronic storage system. The sender does not authorize the use, distribution, disclosure or reproduction of this email (or any part of its contents) by anyone other than the intended recipient(s). No representation is made that this email and any attachments are free of viruses. Virus scanning is recommended and is the responsibility of the recipient.
Here is my follow-up to the list-serve for the situation I described concerning the Humana pre-auth denial of test sockets and what we did. The responses I got from the list-serve pretty much coincide with what we had to do with this specific situation.
1. We contacted the patient to inform them of what was going on and our action plan. We told them to be aware of the denial and we may need their help to contact Humana and what may transpire (may have to sign an ABN form) in the event Humana refuses to authorize the test sockets.
2. I contacted Joe McTernan at AOPA and discussed the situation, was informed that they are supposed to provide the services according to Medicare's guidelines but they have latitude that doesn't seem to be public knowledge or in written format for what they can or can't do.
3. We called Humana back, got a different representative, and magically when we told them these are covered and have been paid for by Medicare that they are now authorized, of course we have documented who, what time, and phone number of the rep.
4. I was prepared with a copy of the LCD, my dictation that documents the medical need for the test sockets, and the reason for the new prosthesis. They did not ask or need that information as we were told the other representative was wrong.
I thank all of you for responding, there were many people who have had similar denials and took action (similar to what we did outlined above) to get things taken care of properly. Some people misread my statement and assumed that I had already delivered the prosthesis. The patient did not receive the prosthesis yet, we always call the Medicare Replacement plans give them all the Lcodes and then they tell us which ones need pre-auth (seems weird that they tell us some codes need pre-auth and some don't so we don't take any chances and call on every patient that has these type plans.) The prosthesis is replacing one that is over 5 years old, can't be modified anymore (all modifications documented and billed), and all other paperwork is complete. Because of scar tissue, very prominent distal tibia, and poor surgical results, change in health (all documented for medical necessity in the EMR), the fitting process has required the use of two (documented by our fabrication EMR) test sockets. The patient has had several health and family challenges that have delayed the delivery process by many months. We are preparing to deliver now so we wanted to make sure everything is still ok before delivery/billing. We do not separate the test sockets for billing. With the new changes in Medicare which requires a detailed prescription signed by the doctor to be in the file at the time of delivery not before billing, makes me hesitant to have to harass the doctor for two different prescriptions for one prosthesis. We are now routinely asking for physician notes for every patient that comes in for a new device and most of the physicians are very understanding so I don't want to inundate them with additional prescriptions. The patient has been informed the whole way so they understand all the garbage we put up with just to get paid (and hopefully keep our money.) We will always appeal and fight for every challenge we get and I encourage all of us to do so or we will not survive. We are such a small voice in a large forest that if we don't keep screaming no one will hear us.
Thanks again for this valuable resource,
Rick Stapleton, CPO
President
NOTE: The information in this email and any attachments may be confidential and/or medical privileged. Access to this email by anyone other than the intended addressee is unauthorized. If you are not the intended recipient (or the employee or agent responsible for delivering this information to the intended recipient), please notify the sender by reply email and immediately delete this email and any copies from your computer and/or electronic storage system. The sender does not authorize the use, distribution, disclosure or reproduction of this email (or any part of its contents) by anyone other than the intended recipient(s). No representation is made that this email and any attachments are free of viruses. Virus scanning is recommended and is the responsibility of the recipient.
Citation
Rick Stapleton, “Humana,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/234826.
