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  • Problems With Humana Claims? Let APTA Know

    Physical therapists (PTs) in several states are reporting claims difficulties with Humana's commercial and Medicare Advantage insurance plans, but more input from providers is needed.

    Recently, PTs from several states including Florida, Ohio, Kentucky, Louisiana, Virginia, and West Virginia have contacted APTA about Humana-related payment issues that include the retroactive application of the multiple procedure payment reduction (MPPR), further reductions to in-network providers' rates through the MPPR, confusion around Humana's approach to anatomical modifiers, and inconsistent application of the 59 modifier, with denials occurring even when the modifier was visible on the claim.

    In addition, the association has received reports of providers having difficulty accessing Humana personnel to discuss claims issues, and a lack of notification when policies and processes change.

    APTA staff have been in discussion with a representative from Humana to facilitate a resolution to the problems. As part of those efforts, APTA is urging members to contact the association by email at advocacy@apta.org, or by phone at 800/999-2782, extension 8511, to share any new or ongoing issues they've had with Humana.

    Need more information on retroactive claims denials and adjustments? Check out this APTA webpage. Also available: resources from Humana on postpayment recoupment, claims coding processing edits, and gaining a better understanding of other Humana processes.


    • Humana is corrupt. They attempted to recoup approximately 20 claims from my private practice secondary to coding criteria. When we called, we talked with operators from the Philippines. They read the script and had no specific answers as to why they were denying our claims. Our notes were thorough and documented with time. Finally, we had to call our US senator , Lindsey Graham, who got the ball rolling. We finally got the results and our claims were than accepted. It was a big hassle for approximately six months. I had to hire a medical attorney to help also. With much frustration, Mark W

      Posted by Mark waldrop on 9/27/2017 4:29 PM

    • When my private practice was happening I was willing to do just about anything to get Humana to pay for services rendered or I would make special arrangements with the patient who preferred to obtain their PT through my clinic. It was a major headache, but my patient always came first!!!

      Posted by Ted Washburne on 9/27/2017 6:44 PM

    • They pay nothing correctly in Florida. I mean nothing.

      Posted by LINDA J ZANE on 9/27/2017 8:45 PM

    • We have similar experience as above comments. It is impossible to reach anyone on the phone. Comments are vague and they are denying the use of CPT code 97110 without any consideration to our documentation. It is frustrating to deal with Humana. The APTA and FPTA are very helpful and I truly recommend speaking with the advocacy group.It is a good idea to contact our Senators.

      Posted by Colette Amit on 9/28/2017 10:12 AM

    • We had so many problems with Humana (basically everything outlined in the article) that we don't even accept that insurance anymore. It was a great decision!

      Posted by Becky on 9/28/2017 1:01 PM

    • I have had issues in the past and current issues with Humana. In the past the APTA was not helpful to the situation. :(

      Posted by George Herbig on 9/28/2017 1:34 PM

    • We find Humana almost impossible to work with and to get corrections made to their own coding and payment mistakes. They ignore modifiers when they are clearly on the claim forms and do not even follow they own re-imbursement fee schedules which are plainly online. When you call to rectify problems there is a canned statement to go to the web-site for the answers and they think they have done their job. They have been unwilling to re-negotiate our reimbursement since the inception of our contract in the late 90's. I guess our cost to supply competent care never goes up but their premiums sure do. As well, a great number of our patients are paying co-pays which equal the pitiful reimbursement we are getting and they think they have insurance. The insurer is getting away with no expenditure because they have been allowed to game the system using our insurance lobby enrichened legislators to get away with it. As well, the Medicare Replacement plans are allowed to pay far less than Medicare Fee Schedule when we , as taxpayers, are subsidizing them by an avg of 14% . Whose guaranteeing us as providers a profit? ....Nobody!

      Posted by Dave Young on 9/28/2017 2:37 PM

    • In SNF setting Humana allows max of 30 days, then they demand discharge regardless of patient l’s status. In cases where patients have PLOF of being independent with all mobility, then have a stroke and require Total assist with all mobility at admission, clearly progressing, but still far below PLOF they demand d/c, and always say patient is either plateaued or at PLOF with no middle ground. Humana is the real world example of a prelude to the feared “death panels.”

      Posted by Bill Bieker on 9/29/2017 8:52 AM

    • I work in acute care. Humana has always been nothing but a giant bear to work with. they constantly deny my pt's rehab opportunity at SNF for Inpt despite my repeated documentation that the pt is not safe to go home. When I have been able to get a rep on the phone the response is always "well the phone nurse who assessed the pt says they can go home". Really?! first of all it is a nurse making the call not a PT-problem, 2nd it is via the phone not actually seeing the pt. I had a pt they denied despite my doc with the berg balance scale that her score placed her at 100% likliehood of falling, I then repeated the berg , showed pt had a 10 point change which is clinically significant meaning pt is making progress in PT but she still scored in the highest fall risk range of about 38/56. I documented all this, put it in layman's terms as to what it meant and they still denied the pt. That pt went home and died 3 days later. When I brought the case up to my administration, my administration contacted humana who said they could not help us as I did not have a DOB--I had an MRN number. Ridiculous. I tell all my pt's to switch to traditional medicare as humana is great if your are healthy but if you need any type of rehab services you are screwed.

      Posted by Allison Bush on 9/30/2017 11:23 PM

    • Humana in KY is denying claims for no "authorization", when in fact we have documented authorization on file from the start of tx. They are royally screwing small businness!

      Posted by Ron Pavkovich on 10/9/2017 9:50 AM

    • I am experiencing the same problems in OP PT clinic in KY as well. We are getting claims paid initally and then recoupments after they "review" the claim. They are claiming the "documentation doesn't support the codes billed" despite the documentation being excellent and clearly outlining medical necessity and what was performed each treatment. It is completely FRAUDULENT and illegal! Not sure what to do from here, but don't want to spend money on a medical attorney. I guess the next step is getting KPTA involved and contacting legislature?

      Posted by Joey Baribeau -> =KQb@I on 10/11/2017 3:36 PM

    • In Louisiana, several private practices are having an issue with denied claims due to no authorization, but they in fact do have authorization. Orthonet blames Humana, and Humana blames Orthonet, in the meantime we have to incur additional expense in submitting these claims and can't get a state side representative with Humana...ever. Keep reporting this to the APTA, your state chapter, and Senetors and Representatives everyone!

      Posted by Lisa Taglauer on 10/20/2017 2:05 PM

    • There need to be repercussions for insurance agencies that pull this garbage. We end up footing the bill for all of the wasted time and additional administration while they get away with paying nothing for the problems and costs they caused. This needs to be addressed by legislation at both the state and federal level.

      Posted by Richard Zaruba on 10/27/2017 3:19 PM

    • They have same problems in the private sector. They ought to be put out of business!

      Posted by Susan Sumsky on 11/17/2017 2:04 PM

    • Humana denied my Dad who was rehabbing from a fall from the nursing home in three weeks. Sent him home only to continue falling. Now after a stroke, they are doing it again in three weeks even though they have to use a Hoyer lift to move him. How is it that he is ready to go home when I cannot move him without a Hoyer lift and a sling. He was making good progress in PT and OT.

      Posted by Dennis Heimerman on 1/15/2018 12:06 PM

    • Our small PT clinic has a few Humana Mcr Advantage with the same plan. They have paid on one patient,denied another and started paying on one , only to deny later for lack of a code that is clearly visible on the claim form. When I called, I spoke to someone who's broken English was so poor I had to ask for someone else to talk to. When I finally got someone else they said we we not providers who were signed up with Humana....(even though they had paid on previous claims.) I am so tired of the run-around by these Advantage programs. Enough is enough!

      Posted by ANITA SAFFORD on 5/3/2018 5:43 PM

    • I have Humana PPO Advantage. I got this plan after my doctor told me I could not put off disability any longer because I'm risking my ability to continue walking and more by continuing to work. I was approved for disability in 3 weeks due to a birth defect in my cervical spine. My cervical spine is backwards curving the wrong way. I had no idea until I suffered a spontaneous break while at work in ER Triage. My neck collapsed crushing discs, causing nerve damage, and I couldn't use my left arm at all. My scans looked like I was in a major rollover type accident. After surgeries, physical therapy, and several nontraditional therapies my doctors agreed that I needed pain mgmt and that's all I was offered. I was started on end of life pain medications on my first visit and I was told I needed these multiple medications and needed them increased often. I was never warned about any side effects. I knew if I continued following my pain mgmt doctor's orders I would not be alive today. Three years ago I quit pain mgmt and got medical help to get off all the medications and I've been clean from them almost three years exactly. The clinic I go too doesn't file any insurance and I have to pay 100% out of pocket and file myself for reimbursement. I've filed, refiled, and refiled again and again only to be denied due to incorrect billing. Each time it's another excuse. I've done my homework and use the most current diagnosis and procedure codes and still denied. I've been trying to get reimbursed for over $5,000 I've paid since 2015 and I'm getting the run around. I know they think I'll just give up but I'm about to appeal. I could use some help if anyone knows insurance and is familiar with Humana. This has been a nightmare. Since getting help to stop pain mgmt I've had zero pharmacy claims, no ER visits, no admissions to the hospital, and I'm saving Humana a fortune!

      Posted by Frustrated Patient on 5/11/2018 10:40 PM

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