Complaint Review: Humana Health Insurance

I would never doubt the word of a Humana rep (cough, cough).

Fine, Franzg, don't believe me. If you or the original person think you're being scammed, please call the DOI so they can tell you how stupid you are.

Yes, Humana policy states that my saliva in a cup is an outpatient visit. So $100 fee must be collected from client.

I was reading this argument between everyone here, and I have to say as a Humana employee, I see this situation alot.

Just to clarify, if you, or a sample or you such as blood or biopsy material, is sent to a hospital for lab tests, then your outpatient hospital benefits will apply. Whoever said that a claim can only be inpatient or outpatient was right on the money. If you aren't staying in a hospital for more than 24 hours, it is outpatient.

To slap a $100 surcharge to run a drop of blood through a machine because the machine was located in a hospital is a ripoff.

Even if Humana has hidden this fee somewhere in the small print, and feels entitled to slap this ridiculous fee on the consumer, it is still a ripoff.

The client should have commissioned a stretch limo to bring the blood to a lab located outside of a hospital. It would have been cheaper, and more fun for the blood.

Reddhedd, all I'm saying is, stick with what you know.

I've worked in a hospital for 15 years doing coding and billing for medical claims.

You've been a Barney Fife police officer for 30 years eating greasy doughnuts and beating false confessions out of helpless minorities.

So, I'd say I'm the expert here when it comes to health insurance; especially since I'm also a Humana member myself.

I'm not disagreeing with your opinions. I'm telling you facts. This claim was for outpatient diagnostic testing. It processed as such. So where is the ripoff?

If you feel that Humana is trying to put one over on you, by all means, contact the Department of Insurance. They'll tell you the same thing that I have, so get ready.

Don't expect further responses from me. Frankly, you're as boring and small minded as Franzg.

It is obvious by the doughnut remark that you can dish it out but you can't take it.
You lash out at everyone on this site for having an opinion that differs from yours.
I have no problem believing for one second that you work in the Healthcare field.
Not after what I've read. I guess you missed the part that all major companies record their calls. I guess you were absent that day, and I think you slept through the day they covered common sense. You like to pick out other peoples' errors while skimming over your own.
The Screen name says it all and makes it that much more amusing that an obvious "People Person" like you works where you do.
I happen to love doughnuts, what I love more is being able to chap the *ss of some self-important jerk who has very thin skin and obvious self-image issues.

You have a great day!

P.S. Getting a life wouldn't hurt either.

Reddhedd, if you noticed, I ASKED if taping people without their consent was legal. I didn't DECLARE it was illegal.

Please try to pay attention.

As for my experience, I run a billing and coding department for a major Chicago hospital. I've done this for over 12 years. Before that, I was in a non-supervisory role there for about 3 years. I think that qualifies me as an expert in these situations over you.

If someone needed information on where the best doughnut shops are, that'd be your area of expertise.

I have read several of your responses, and have concluded that you clearly don't know as much as you think you do. As a retired Police officer of 30+ years, I can say I have come across people that think as you do. If you read my complaint, you would have seen the part that says I am in the appeals process. I have complied with all their criteria, and the list is long. I am no stranger to documentation and paperwork, and I deal in proof and facts. I don't brow-beat anyone that has a different opinion. You obviously view yourself as an expert. The question is...an expert at what?
As far as you questioning the legality of my "taping" a conversation I was having with a Company Rep, let me enlighten you...Any conversation that is recorded by one party in conversation with another party is legal. What is illegal is taping the conversations of others that you are not a party to, without their permission or knowlege. If you are as "experienced" as you say, you would know that all the major health carriers tape their phone calls. Did you catch that...or were you still laughing? I guess they are not only committing a crime, but being "ridiculous". You claim to be knowlegable about Health Care issues and definitions, when in fact, your response is the one that is ridiculous.
I have put my concerns in writing and am following the appeals process. I taped the conversations for the same reason Humana does. Humana Rep's can claim no such conversation took place and if they have the only audio tape...I guess it would be my word against theirs. That might work for you, but I prefer both sides of the story be presented. I have read the definitions of my out-dated certificate carefully. The problems with Humana are too numerous to detail and I was not aware that the Certificate of Coverage is open to such broad interpetation. How ridiculous of me!

There is absolutely no record of this client being confined to a hospital less than 24 hours.

As a matter of fact, there is no record of this client ever being a patient in this hospital.

The client was simply never in the hospital at all, in any way, shape or form.

It is not an outpatient vs. inpatient issue. It is a lab test.

Stop wasting everybody's time.

Look at how many back and forth responses we've had, Franzg.

There's no point talking to you anymore, you just can't admit that someone knows more about these kind of things than you. So, congrats, I quit. But I will leave you with the following:

This is an outpatient hospital lab test. Because
1. It's obviously diagnostic lab work.
2. It was done at a hospital.
3. The patient wasn't confined to the hospital for over 24 hours.

These are medical facts.

If you want to dispute that, take it up with the medical community because these benefits applied perfectly.

Buh-bye!

OP had lab test.

Whatever, Franzg. Oops, sorry, Opana. You shouldn't have any kind of credentialling if you don't know the difference between inpatient and outpatient services, let alone not knowing how to spell common everyday words. It makes me wonder how you actually passed that test. Hmmmm.

Look up Cheektowaga NY. It's a real town. I am not your "rival". I passed the national exam adminstered through the Amercian Case Management Society in 2006, and I am a certified registered nurse case manager(CCM). Health care reimbursement, health care delivery systems and claims coding were significant parts of the exam. I know I got the inpatient/outpatient question correct!
As far as my grammar, my husband is physician and he thinks I speak fine. Of course, I speak Polish much better.

Yes, I kind of notice a pattern with these reports that clarity is an issue here. Often a client complains because there are conflicting clauses in the certificate, and they are given wrong info when they call Humana to clarify.

Simplifying the jargon in the contract would help. Also, opening a complaints department and consumer hotline would help as well.

These simple measure would enhance customer service and satisfaction, and make Humana's product more palatable to the general public.

Ok, I'll play along, Franzg. Opana, if you really are in the position that you say you are, I'm sure you'd have much better grammar and spelling skills. Anyone with an even basic knowledge of claims processing and healthcare should know the difference between inpatient and outpatient services. You're a liar, and a bad one. You're just trying to one-up me since I work in healthcare.

I don't know who you're calling when you ask for benefits for a patient, but it's been my experience that Humana is actually one of the better ones when it comes to quoting benefits.

Keep those stories coming!

I am a real person. I've been an RN for 28 years at the same hospital working in a variety of positions. I am currently the director of a case management department in an hospital. I agree that dealing with insurance companies is so frustrating. My staff deals with them all time. Customer service reps don't necessary lie, but they are usually just high school grades who aren't too smart. Yes, I've been misquoted prescription benefits by a rep, had the doctor order the medication for the patient and then found out from the pharmacy that cost of the was 50% not $5.00. What we need is to demand transparency and in plain 6 th grade lanaguage regarding what is and isn't covered in a policy and then receive this in writing. This way the consumer knows what they're getting or not getting. But then policyholders have to be responsible for reading their policies as well. It is a two way street.
Have a most excellent day!

WTF is wrong with you anyway?

Your having a little problem with paranoia. Is this really that important to you?

You really should take better care of yourself. Go to the beach. Take a deep breath. Join a yoga class. It may clear up your perspective on things.

WTF is wrong with you anyway?

Your having a little problem with paranoia. Is this really that important to you?

You really should take better care of yourself. Go to the beach. Take a deep breath. Join a yoga class. It may clear up your perspective on things.

WTF is wrong with you anyway?

Your having a little problem with paranoia. Is this really that important to you?

You really should take better care of yourself. Go to the beach. Take a deep breath. Join a yoga class. It may clear up your perspective on things.

So Franzg is pretending to be a healthcare rep now? Opana? Where'd you come up with that name Franzg?

Sorry to disagree,but in no way, shape or form does this quaify for an Outpatient Procedure Charge. This is a lab test and a lab draw. I don't know where some of this misinformation is coming from, but some one from Humana put in the wrong procedure codes. Even if the patient came to the hospital for the lab work, that's not subject to an outpatient procedure charge. Big difference between lab work and a procedure. The customer service reps are usually not very smart, so that doesn't surprise me. This lady should fight these charges as Humana is in error.

My saliva is in a hospital-

Does that mean my saliva is an outpatient?

Maybe Humana needs to bill my saliva for being an "outpatient"

I'll give you a hint- my saliva was not actually "sent" to a hospital.

Some of my phlegm may be in the saliva. Do I now owe Humana $200?

I used the restroom. Now my Urine is in the hospital! OMG I need to cough up another $100!

In another instance, I exhaled, and tiny particles of air came out of MY lungs. I must owe Humana more. I'm an official outpatient.

I was an inpatient at one time. While I was in the hospital, a drop of blood fell to the floor- Now I'm an inpatient and an outpatient at the same time! I'm so confused.

That's why I fail to believe this BS

Even if you think it should cost $100 more for my saliva to be in a hospital, it is quite unnerving to be charged $100 for it.

I'm sure Humana would be glad to waive the $100 fee for the drop of my sweat that accidentally fell on the $100 bill I needed to fork over.

I agree w/ OP. Humana is a ripoff

I realize that not everyone has my expertise in the field of health insurance, so let me break down the definitions of inpatient and outpatient services.

Inpatient: this is where the member is confined to a facility for more than 24 hours. It's that easy.

Outpatient: this is where the member is confined to a facility less than 24 hours. It also applies to the patients biological material (blood, urine, saliva, skin samples, etc. etc.) and not the patient themselves being sent to a facility for testing or analysis.

That being said, we have
1. a lab test
2. it was done at a hospital
3. it was outpatient

Um, so why are we surprised that the outpatient hospital benefits applied?

The "certificate" covers a lab test.

I'm sorry you think that the client was a hospital outpatient.

Adding these phony fees saves Humana the money it desperately needs. Something owes this client $100, and I suspect it is Humana.

Too bad for you. I don't work for a managed care company. Your corny accusations are a sign of desperation.

Now go have your lab tests done in the outhouse in your backyard. According to Humana, it is the benefit perfectly applied in your "certificate", and will save you $100.

Franzg said, "I would apply the benefit as stated in the certificate,
The benefit as stated in the certificate is for a lab test".

The benefits applied perfectly. Let's break it down like this. It's a lab test. It was done at a hospital. The patient was not confined to the hospital.

lab test + hospital + outpatient = outpatient hospital lab test.

You work at a managed care company. How could you not know this?

The benefit as stated in the certificate is for a lab test.

A couple of drops of blood are sucked into a giant machine which later spews a printed report.

Manufacturing an "outpatient visit" out of this procedure seems ludicrous to me.

It is wasteful and inefficient to charge more for the same procedure on the sole basis of the machine's owner.

Someone owes this victim $100.

So Franzg, I guess the fact that I've done Billing and Coding for a hospital for twelve years doesn't mean anything to you in this case. Oh well, I'll ask again... Labwork can only be done in one of three environments... A physician's office, a hospital, or an independent lab. That being said, to get the hospital paid, what benefit would you apply? I would welcome an answer instead of a political comment.

You physically don't have to go to a hospital to have services done at a hospital. The same thing could happen if you get a MRI and the results are sent off to a hospital for interpretation.

Your certificate comments are getting old. Using your logic, I suppose if a Humana member poisoned the town's water supply, they'd get away with it "because it didn't say they couldn't do it in the certificate". Apply some common sense.

Dear I Am The "Flaw"-
The client never visited the facility, therefore client was never an "outpatient".

Is that illogical?

The client never filled out an intake form for a clinic visit. Therefore, the client is an "outpatient".

Is that logical?

If you had a blood sample sent to a lab, would you be willing to pay for an outpatient visit?
I don't think so. It is not logical.

Logic would conclude that someone owes the client $100.

Logic would also require that Humana be more clear about the lab tests it covers. This client is getting the runaround. Please help the client. It does not say in the "certificate" that lab test equals outpatient visit. You are essentially telling us the "certificate" is in error. The client was charged for an outpatient visit, which requires deductible payment. The "certificate" has now caused 2 errors. It is flawed, just like your logic.

I don't think we should be spending $640 billion a year for these flawed "certificates" anymore. They are unclear and illogical.

Franzg said,...... "Humana weasles out of paying for covered labwork by claiming several molecules of a client's blood represents an outpatient visit subject to deductible. It is not in the 'certificate'"

Rebuttal: Um, ok, first of all, like I said before, labwork can only be done in one of three environments: a doctor's office, an independent lab, or a hospital. Can we not go Christian Bale psycho and at least agree on that? So, according to the member's policy (again which the employer wrote), you have different benefits based on which type of facility you go to. That being said, what type of benefit do you think should apply? It's not a doctor's office, it's not an independent lab (such as Labcorp or Quest Diagnostics), so that makes it (GASP!) an outpatient hospital claim!

The patient even said,...... "He (the doctor) is not close to a lab and has permission to send his lab work to the Hospital two miles away, to be tested in their lab. It was catagorized as lab work only."

I guess you didn't notice that the words "hospital" and "lab work" were in that statement.

Second, obviously the outpatient hospital labwork benefits are listed in the certificate or the benefit wouldn't be covered at any level.

Logic works for everyone else. Why aren't you using it?

You can't fight these people. Us conumers should just roll over and die, i guess.

Case #1- Humana weasles out of paying for covered labwork by claiming several molecules of a client's blood represents an outpatient visit subject to deductible. It is not in the "certificate".

Hooray, Humana 1, consumers 0

Case#2- Humana claims you must check every employee at a facility to make sure they are "in network" before expecting payment. After all, when we shop for groceries, we are looking very hard for bargains, so why not check every employees' affiliation with Humana, right? If I was coughing up a percentage of my earnings every month for someone to pay for my groceries, I would expect they would do a fairly decent job. I would not expect them to ask for a list of the prices of every item in every grocery store before doing what the "certificate" dictates. Humana's "certificate" does not require the consumer to check every hospital, clinic or lab employee in their region.

Chalk up another for managed care- Humana 2, consumers 0

$640 billion a year for this crap. Sounds like taxpayers get the shaft again! Bernie Madoff would be proud of Humana for getting away with this.

You can't fight these people. Us conumers should just roll over and die, i guess.

Case #1- Humana weasles out of paying for covered labwork by claiming several molecules of a client's blood represents an outpatient visit subject to deductible. It is not in the "certificate".

Hooray, Humana 1, consumers 0

Case#2- Humana claims you must check every employee at a facility to make sure they are "in network" before expecting payment. After all, when we shop for groceries, we are looking very hard for bargains, so why not check every employees' affiliation with Humana, right? If I was coughing up a percentage of my earnings every month for someone to pay for my groceries, I would expect they would do a fairly decent job. I would not expect them to ask for a list of the prices of every item in every grocery store before doing what the "certificate" dictates. Humana's "certificate" does not require the consumer to check every hospital, clinic or lab employee in their region.

Chalk up another for managed care- Humana 2, consumers 0

$640 billion a year for this crap. Sounds like taxpayers get the shaft again! Bernie Madoff would be proud of Humana for getting away with this.

You can't fight these people. Us conumers should just roll over and die, i guess.

Case #1- Humana weasles out of paying for covered labwork by claiming several molecules of a client's blood represents an outpatient visit subject to deductible. It is not in the "certificate".

Hooray, Humana 1, consumers 0

Case#2- Humana claims you must check every employee at a facility to make sure they are "in network" before expecting payment. After all, when we shop for groceries, we are looking very hard for bargains, so why not check every employees' affiliation with Humana, right? If I was coughing up a percentage of my earnings every month for someone to pay for my groceries, I would expect they would do a fairly decent job. I would not expect them to ask for a list of the prices of every item in every grocery store before doing what the "certificate" dictates. Humana's "certificate" does not require the consumer to check every hospital, clinic or lab employee in their region.

Chalk up another for managed care- Humana 2, consumers 0

$640 billion a year for this crap. Sounds like taxpayers get the shaft again! Bernie Madoff would be proud of Humana for getting away with this.

CASE #1: You said, "he (the doctor) is not close to a lab and has permission to send his lab work to the Hospital two miles away.." Um, ok, so the sample went to a hospital and you are wondering why the outpatient hospital benefits applied? What kind of benefits would you like applied? Your lab work can only be done in one of three environments, a doctor's office, a hospital, or an independent lab.

RULING: Humana.

CASE #2: You said, "My husband needed a stress test and went to a Cardiac Clinic in a Larger City that was In-Network, so we figured we were safe. Wrong! One of the employees that was on the bill, was not In-Network. This place had over a hundred employees. We have Tiffany on tape saying that it is the patient's responsibility to check each and every person, at the facility, who could possibly be involved in your treatment... prior to treatment...even if there are hundreds." Yes, this is absolutely 100% true, when it's possible. Obviously if you're unconscious in an ER or something, that's not going to happen, but I don't think it's unreasonable for a patient to take the responsibility to look into this. If anything, it's beneficial to the patients since contracted providers are subject to price control through your policy. It's amazing to me the effort people will go to to find the cheapest groceries or lowest interest rates on loans, but they won't make the same effort with their health care.

RULING: Humana.

Other humorous statements in this ROR.....

"This company makes it nearly impossible for you to find out what your coverage is and then changes the wording in the agreement to find a way to deny coverage or get a larger deductible"

Rebuttal: Try calling Humana or looking online. Obviously you acess to a copy of the certificate too in your employers office or if this is indeed a Medicare plan (can't figure it out from your story), you can view it online. By the way, deductibles are paid to the provider, not Humana. Also, certificates are legal documents; they can't be "reworded". That'd be like your bank rewording your contract with them so you had to pay for your house for 20 more years or something.

"We have Tiffany on tape..."

Rebuttal: Ok, this one just about takes the cake. You're taping people? Not sure if that's legal or not, but even if it is, it's not admissable in court anyway (if that was your intention). Why are you taping people?


"It doesn't say that in the certificate either..."

Rebuttal: Then why does you certificate and benefits materials constantly refer to going in network?

Ok, I'm done now. Have a nice day.

CASE #1: You said, "he (the doctor) is not close to a lab and has permission to send his lab work to the Hospital two miles away.." Um, ok, so the sample went to a hospital and you are wondering why the outpatient hospital benefits applied? What kind of benefits would you like applied? Your lab work can only be done in one of three environments, a doctor's office, a hospital, or an independent lab.

RULING: Humana.

CASE #2: You said, "My husband needed a stress test and went to a Cardiac Clinic in a Larger City that was In-Network, so we figured we were safe. Wrong! One of the employees that was on the bill, was not In-Network. This place had over a hundred employees. We have Tiffany on tape saying that it is the patient's responsibility to check each and every person, at the facility, who could possibly be involved in your treatment... prior to treatment...even if there are hundreds." Yes, this is absolutely 100% true, when it's possible. Obviously if you're unconscious in an ER or something, that's not going to happen, but I don't think it's unreasonable for a patient to take the responsibility to look into this. If anything, it's beneficial to the patients since contracted providers are subject to price control through your policy. It's amazing to me the effort people will go to to find the cheapest groceries or lowest interest rates on loans, but they won't make the same effort with their health care.

RULING: Humana.

Other humorous statements in this ROR.....

"This company makes it nearly impossible for you to find out what your coverage is and then changes the wording in the agreement to find a way to deny coverage or get a larger deductible"

Rebuttal: Try calling Humana or looking online. Obviously you acess to a copy of the certificate too in your employers office or if this is indeed a Medicare plan (can't figure it out from your story), you can view it online. By the way, deductibles are paid to the provider, not Humana. Also, certificates are legal documents; they can't be "reworded". That'd be like your bank rewording your contract with them so you had to pay for your house for 20 more years or something.

"We have Tiffany on tape..."

Rebuttal: Ok, this one just about takes the cake. You're taping people? Not sure if that's legal or not, but even if it is, it's not admissable in court anyway (if that was your intention). Why are you taping people?


"It doesn't say that in the certificate either..."

Rebuttal: Then why does you certificate and benefits materials constantly refer to going in network?

Ok, I'm done now. Have a nice day.

CASE #1: You said, "he (the doctor) is not close to a lab and has permission to send his lab work to the Hospital two miles away.." Um, ok, so the sample went to a hospital and you are wondering why the outpatient hospital benefits applied? What kind of benefits would you like applied? Your lab work can only be done in one of three environments, a doctor's office, a hospital, or an independent lab.

RULING: Humana.

CASE #2: You said, "My husband needed a stress test and went to a Cardiac Clinic in a Larger City that was In-Network, so we figured we were safe. Wrong! One of the employees that was on the bill, was not In-Network. This place had over a hundred employees. We have Tiffany on tape saying that it is the patient's responsibility to check each and every person, at the facility, who could possibly be involved in your treatment... prior to treatment...even if there are hundreds." Yes, this is absolutely 100% true, when it's possible. Obviously if you're unconscious in an ER or something, that's not going to happen, but I don't think it's unreasonable for a patient to take the responsibility to look into this. If anything, it's beneficial to the patients since contracted providers are subject to price control through your policy. It's amazing to me the effort people will go to to find the cheapest groceries or lowest interest rates on loans, but they won't make the same effort with their health care.

RULING: Humana.

Other humorous statements in this ROR.....

"This company makes it nearly impossible for you to find out what your coverage is and then changes the wording in the agreement to find a way to deny coverage or get a larger deductible"

Rebuttal: Try calling Humana or looking online. Obviously you acess to a copy of the certificate too in your employers office or if this is indeed a Medicare plan (can't figure it out from your story), you can view it online. By the way, deductibles are paid to the provider, not Humana. Also, certificates are legal documents; they can't be "reworded". That'd be like your bank rewording your contract with them so you had to pay for your house for 20 more years or something.

"We have Tiffany on tape..."

Rebuttal: Ok, this one just about takes the cake. You're taping people? Not sure if that's legal or not, but even if it is, it's not admissable in court anyway (if that was your intention). Why are you taping people?


"It doesn't say that in the certificate either..."

Rebuttal: Then why does you certificate and benefits materials constantly refer to going in network?

Ok, I'm done now. Have a nice day.

CASE #1: You said, "he (the doctor) is not close to a lab and has permission to send his lab work to the Hospital two miles away.." Um, ok, so the sample went to a hospital and you are wondering why the outpatient hospital benefits applied? What kind of benefits would you like applied? Your lab work can only be done in one of three environments, a doctor's office, a hospital, or an independent lab.

RULING: Humana.

CASE #2: You said, "My husband needed a stress test and went to a Cardiac Clinic in a Larger City that was In-Network, so we figured we were safe. Wrong! One of the employees that was on the bill, was not In-Network. This place had over a hundred employees. We have Tiffany on tape saying that it is the patient's responsibility to check each and every person, at the facility, who could possibly be involved in your treatment... prior to treatment...even if there are hundreds." Yes, this is absolutely 100% true, when it's possible. Obviously if you're unconscious in an ER or something, that's not going to happen, but I don't think it's unreasonable for a patient to take the responsibility to look into this. If anything, it's beneficial to the patients since contracted providers are subject to price control through your policy. It's amazing to me the effort people will go to to find the cheapest groceries or lowest interest rates on loans, but they won't make the same effort with their health care.

RULING: Humana.

Other humorous statements in this ROR.....

"This company makes it nearly impossible for you to find out what your coverage is and then changes the wording in the agreement to find a way to deny coverage or get a larger deductible"

Rebuttal: Try calling Humana or looking online. Obviously you acess to a copy of the certificate too in your employers office or if this is indeed a Medicare plan (can't figure it out from your story), you can view it online. By the way, deductibles are paid to the provider, not Humana. Also, certificates are legal documents; they can't be "reworded". That'd be like your bank rewording your contract with them so you had to pay for your house for 20 more years or something.

"We have Tiffany on tape..."

Rebuttal: Ok, this one just about takes the cake. You're taping people? Not sure if that's legal or not, but even if it is, it's not admissable in court anyway (if that was your intention). Why are you taping people?


"It doesn't say that in the certificate either..."

Rebuttal: Then why does you certificate and benefits materials constantly refer to going in network?

Ok, I'm done now. Have a nice day.

I find it distressing that the carrier (one who pays claims) can't help this victim.

I also find it distressing that Humana employees on this site can't help this victim.

I don't believe Humana is only out to get our money. I believe Humana already has our money. Humana gets to keep our money by denying our claims, and making appeals nearly impossible. The runaround this victim got is part of the managed care process that insures these companies will be profitable in the future.

The victim has been left with several options by Humana- Check EVERY paid employee at EVERY healthcare facility you (or your blood) come in contact with to make sure they are "in network". If that doesn't work, file a written appeal, so Medicare can review it (I really doubt you will get any response from this course of action). Call the HR person at your "employer" (in this case, a city government), and ask for clarification (I doubt this would help either).

The victim was never an outpatient at the lab. The $100 fee should be refunded. Face reality.

I guess the next time Humana sends me a piece of mail to my residence, I will check the mail for DNA, and have it charged with trespassing, since part of its body entered my house without prior authorization.

Hi Red,

I'm not sure I can help with the first part of your problems regarding the lab work. That doesn't sound right to me either, so I'd have to see the claim. Important thing to know is the people you are going to speak to on the Customer Service lines aren't always the most knowledgeable on such matters.

But I can tell you for certain there is a solution to the second part of your problems (regarding the rendering physician). Without going into too many boring details regarding how claims processes, claims are dependent on 3 factors: Place of Service, Rendering Physician, and the Tax ID number (TIN) of the entity filing the claim. If you are correct that the clinic you visited is In-Network, and the claim was filed by the clinic, but still processed Out of Network (OON), it's what we call a roster-load issue.

You have a few choices on how to resolve this issue. You can talk to the clinic and have them send an updated roster to their contractor and have them request the claim be reprocessed; you can call customer service again and ask them what entity/TIN filed the claim and inform them that the doc needs to be loaded (I don't recommend this one if you have already have had bad luck with them); you can write a letter of appeal to explain the situation (slowest of the choices); or you can call your Sales Rep (best choice). The Sales Rep can either contact their Market support or their contractor and fix the issue. Make sure you give them a copy of the claim just to make sure they take care of the right one; and don't be afraid to follow up with the Sales Rep regarding the issue--that's what they're paid for.

I hope I've been helpful. Despite that some more regular posters on this forum want to convince you everyone in Humana is just out to get your money, there are people in this company that do want to help (myself included).

Please let me know if you have any more questions regarding this issue and I'll try to lend a hand however possible.

...Or at least I hope not.

If you want to talk politics, go right ahead.

Tiffany was wrong. She did not tell the client to complain to the "employer" (if there even is one).

Politics aside, don't you think it would be more efficient if Humana knew what they cover for each of there clients? Don't you think it would be sound corporate policy to know how much coverage its policy covers for each procedure? It seems to know exactly how much it covers when it collects our premiums and "pays" our providers. Why cant the employees at Humana get it right?

C'mon Humana, stop being stupid, and give us the information we need. The runaround is getting quite old and aggravating.

With all due respect, folks, again, your insurance carrier can quote your benefits and which providers are in or out of network, but the claim can be presented for services or providers completely different than what you asked about. You, the patient, and your carrier have no control over this. You can't ask Humana to predict the future like that.

I obviously can't see the claim, but you were probably asking about diagnostic testing done in a physician's office or maybe an independent lab. If the provider billed as part of a hospital, typically lab services done there are subject to your deductible because they're usually more expensive in that type of environment. (Depending on how your employer wrote your policy.)

Franzg, please stop your criticizing. Your political rhetoric doesn't help anyone here. You can blog all you want, this is a free country, but instead of criticizing Humana and managed care, why don't you listen to me and try to understand the problem? I'm offering possible explanations and solutions here and all you do is spout your hatred.

Now you need to write a "letter".

A simple situation has now become a legal appeal.

Good luck, and I hope it works in your favor. The $100 fee you are being charged does not sound legitimate, no matter what your employer wrote on this "certificate" (peddled by Humana).

Humana health insurance is a defective product with no warranty, no complaints department, and a faulty "appeals" process.

Reddhedd, the reason Humana probably can't send you a copy of the certificate is because your policy is most likely self-written by the employer. That cert should be on file in your HR or benefits office, that's why it's not online.


As for when you said "We have Tiffany on tape saying that it is the patient's responsibility to check each and every person, at the facility, who could possibly be involved in your treatment... prior to treatment...even if there are hundreds". This statement is actually true, when it's pertinent to check. Obviously if you're in a dire emergency situation or unconscious, these things can be appealed later if your provider is not contracted with your carrier. This situation is extremely common in hospitals where a provider will rear their head and they happen to be out of network. Think of all the providers you could interact with at the hospital. There will be claims from the hospital itself, maybe lab people, radiology people, pathologists, anesthesiologists, therapy people, etc. etc. Basically, who knows who will submit a claim and which name or tax ID they'll use. It's not something an insurance carrier can predict or control. Frankly, neither can the patient. My advice is if a out of network provider manages to slide in there unbeknownst to you until after they submit a claim, appeal it. All explainations of benefits will have instructions on how to do this.

If you look at the back of your Explanation of Benefits there is an address for Grievance and Appeals. What you have is an appeal that can and should be filed with the company. I would, in the letter, describe everything as you did here, including the date of the call to "Tiffany" (be sure to mention what you were told, as the information you were given is quite likely incorrect on how this should be handled).

If your doctor is sending your blood to the hospital, and you are not, it can be considered a "Par Directed Service". This means that, after researching the matter, it can be overturned and paid. Your blood simply being in the facility is not the same as a visit to the hospital, and situations like this are not uncommon with every insurance company. Sending a letter gets a case started, and worked, that can and many times does end in a favorable manner for the member. I would strongly urge you to send an Appeal letter, and give Humana a chance to make this right.

For your husband, that is not uncommon either. Although he will have to write a separate letter, because Medicare considers every plan as individual and HIPAA law requires certain measures be taken, research for treatment at a facility (the Cardiac Center) that is in network will most often be research and paid as well if an appeal is filed. Once again, make sure to send in the details of what happened, as well as details and date of your phone call.

I'm familiar with Humana, and Medicare Plans in general, and can tell you both take things like this very seriously. If a Humana employee made incorrect statements to you, they will want to know and resolve this matter. If you don't want to write the letter, I would suggest calling in again concerning this, and giving the representative on the line all the details you did here. Because Humana has three major "call centers" for Medicare plans, the chances of getting Tiffany again, or anyone connected to her, are very low.

Just for reference, you can request a copy of your Evidence of Coverage at any time. If it is a "group" plan, through an employer, you can request this directly from Humana or through the company paying for your plan. If it is an "individual" plan, meaning that you enrolled in it yourself, not through a company or any other large industry, then your Evidence of Coverage can be located at Humana-Medicare.com, typing in your zip code, choosing the plan you have, clicking on "plan details" and scrolling down. There is a link to the plan information towards the bottom, I believe labeled as the Summary of Benefits. Or, and I suggest this again, call again and request Grievance and Appeals information as well as a copy of your Summary of Benefits. If this was for 2008, however, it may be difficult to get a copy of the Summary of Benefits. Some companies do not have copies available for ordering after the plans are no longer effective.

Once again, you do have Appeal rights that I would suggest you use, as both of these situations sound like something that can be easily resolved by the Grievance and Appeals Department of Humana. Medicare does require appeal requests be made in writing, and the address and information is on the Explanation of Benefits received after each claim processes. You can also get the information by calling Humana one more time and specifically requesting Grievance and Appeal rights.

best of luck as you try to get this resolved.