Hassling with Humana

August 14th, 2009 by Editor B

I really hate our whole healthcare/insurance system, which is why I get excited when I hear about reform and discouraged when it seems to go off-track.

This is on my mind today because of the inane interaction I just had with my health insurance provider, Humana.

Back in June, when we were traveling, our daughter got an infected toe, so we went to the nearest convenient place, a “doc in a box” in Bloomington, Indiana.

We paid $25 upfront as a co-pay, and they said they’d bill Humana for the rest.

Humana did not pay, so I got a statement from the doc-box. Total charge: $109.00. Less our $25.00 payment, that’s $84.00 I owe them. A helpful note was included: “Your insurance was filed but did not pay. Your insurance was refiled today. If you have questions contact you insurance. Please pay balance due.” A further note in case you didn’t get the full import: “Your insurance is filed as as a courtesy. If you have insurance questions, PLEASE CONTACT YOUR INSURANCE CARRIER FIRST, then advise us of your claim.”

I got on Humana’s website. I was able to remember my username and password for a change. I accessed the Claim Details. “Status: COMPLETED.” OK, but was it paid? “Paid: 06/23/2009″ Aha, so it was paid? “Humana Paid: 0.00″ Oh, I guess it wasn’t paid.

Then I noticed this little message, which I will reproduce in its entirety.

Message 1: This service was performed by a non participating provider and exceeds the Maximum Allowable Fee (MAF). You are not responsible for the difference between the MAF and the amount the provider bills you for the services.Should you be billed for this, please contact 1-866-427-7478. For additional information please refer to the Schedule of Benefits and Glossary section in your Benefit Plan Documen

The Maximum Allowable Fee, in case you’re wondering, is $91.07. Don’t ask me how they derived that arcane number, but there it is. Apparently I am not responsible for the difference between the MAF and the total charge. That difference is $17.93, and if I’m billed for this, I should call Humana at the number listed.

So I did call. I asked my first question. Why is there a listing for the date the claim was paid, when in fact the claim was not paid? Do you see how that could be confusing? No, the rep maintained, she did not. Well, I said, belaboring the point most egregiously, when a normal human being hears that zero dollars were paid on a certain date, most people would conclude that no payment occurred on any date. So how could Humana list a date for the payment, when there was no payment greater than zero? She confessed she could see how it might be confusing to me, but it was not confusing to her.

Once we got that foolishness out of the way, I asked about the MAF. What’s this $17.93 for which I am “not responsible”? That stumped her, and she had to put me on hold for half an hour, after which time she came back, apologized, and said someone would have to call me back.

I proceeded to bend her ear for a little while longer about Humana’s online database of participating physicians. We’re supposed to use this to find a doctor. But the information is vastly out of date, with most of the physicians in my area flooded out after Katrina. That was four years ago, by the way.

A short while after our friendly chat ended, I got a call back from Humana. The rep explained there is a typo on the website. The text that says “You are not responsible” should read “You are responsible.” Ah, what a difference one little word makes.

Oh, by the way, this medical expense would have been covered if we had just taken the time to call in to Humana and ask for a referral to a participating physician. Never mind that we were on the road and just wanted to get our girl to the nearest convenient doctor. The doctor we chose was not “participating” so we’re not covered.

What part of this system makes any sense?

25 Responses to “Hassling with Humana”

  1. Jenny Rieth Says:

    Say you were NOT responsible for charges beyond the MAF — would that mean the DIB [doc-box] would owe you $7.07???
    PLEASE REFORM HEALTHCARE AMERICA. What happened to the land of the free, with liberty & justice for allllllllllllllllllllllllllllllllllllllllllllllllllllllllll.

  2. Garvey Says:

    It’s cute that you think the currently proposed legislative reforms will mean LESS red tape.

  3. Editor B Says:

    Garvey, it’s not cute that you think you know what I think. Annoying, yes. Cute, no.

  4. Garvey Says:

    I don’t know what you think, but I do know what you wrote. It’s not unusual that one could read this:

    “I get excited when I hear about reform and discouraged when it seems to go off-track.”

    and think that this reform you speak of is somehow related to, um, current events, is it?

    If you can point me to some actual sensemaking reforms that were being widely discussed and have now been derailed, I’d be grateful, because I haven’t heard about them.

  5. Andrea Says:

    Imagine the fun you could have with your insurance if you were REALLY sick!

  6. Editor B Says:

    Reform is needed. The actual proposals being floated in Washington? I haven’t been following closely enough to have an opinion. I am vaguely aware that it doesn’t seem to be going well. That’s frustrating. That’s all. You’re a little too eager to jump the snark, Garv.

  7. Lee Says:

    I agree that reform is needed, I’m not too eager to jump on the bandwagon of one side or the other however. I don’t think our country is ready for socialized medicine (and I don’t think that’s what our elected officials are trying to enact.) I would call their bluff on that typo though. If you push hard enough, they will give. I have seen and done.

  8. Editor B Says:

    Lee, I forgot to mention that the rep conceded I had a case, but I don’t feel like jumping thru the hoops for $17. If it was $170, maybe.

  9. Sean Says:

    I’m curious what doctors have to do to be approved by the insurance companies. Sucks you had to jump through hoops. If it had been a broken bone or worse that’d be a real shocker. I wonder if the doctor’s staff knew it would be denied because they are a non-participating provider…

    For anyone interested in reading and discussing the actual bills… There is so much misinformation (both Dems & Reps) out there people really need to fact check every slanted comment they hear on the news or radio before repeating it:
    HR3200 “Obama’s Plan” here: http://www.opencongress.org/bill/111-h3200/text
    HR676 Single Payer here: http://www.opencongress.org/bill/111-h676/text

  10. David Says:

    In Canada, here’s what Nicole has to do to see a doctor:

    1. She makes an appointment.
    2. She shows up and presents her healthcard.
    3. After her appointment, she forgets about ever receiving a receiving a bill.

    It’s basically a socialist/secret-muslim nightmare devoid of the obvious conveniences you enjoy in the land of the free-market.

  11. julesb_town Says:

    wow- what a mess for you.
    I heard this yesterday and it summed up a lot of things for me.

    http://www.npr.org/templates/story/story.php?storyId=111736487&sc=fb&cc=fp

    peace-
    jules

  12. Dave Z. Says:

    Sounds like the problem is with Humana, the company. I’ve had Blue Cross Blue Shield of Illinois for the past 30 years, my wife and two kids for the past 16- 19 years. Never had a problem, and whenever I did have questions they were always answered quickly and professionally. However, I’ve never had any out-of-state emergencies to deal with. I would imagine that that could be the acid test of an insurance company’s effectiveness and customer service.

  13. Garvey Says:
  14. Garvey Says:

    BTW, B, you’re right and I apologize.

  15. Sherry Says:

    Dear Bart and family,
    So sorry to hear about your family health-care issues. It sounds like what my parents who live in Arizona have also experienced with Humana. Just for comparison: when my mother-in-law was hospitalized with her strokes, when my daughter-in-law had my grandchildren, when my children, my husband and myself were hospitalized for various ailments, broken bones and surgeries, we paid exactly: zero. We see our doctors/specialists as often as we choose, and change them when we want. For each specialist visit, we pay a flat fee of $3. We pay nothing for any prescribed test: blood, x-ray, CT scan, whatever. If we go to an Urgent Care facility or the emergency room, it is 100% covered if we are admitted, otherwise we pay about $12. We pay 10% of the cost of prescribed drugs, or $2.5 per prescription, whichever is greater. We pay a government-levied health tax of 4% on our salaries, up to a very reasonable cap, which is passed on to the health fund of our choice. Of course, all this is in a semi-“socialist” country, Israel….

  16. Peris Says:

    There seems to me to be three kinds of problems people have with health insurance:

    1) You don’t like what it covers (and what it doesn’t)

    2) It’s too complex, and variable: you can’t tell what it does and doesn’t cover at any given time.

    3) Poor/indifferent customer service: you can’t get good help with #1 and #2.

    During times of crisis, you’d like to not have to consider #1, but you’ll pay more if you don’t.

    We need a competitive market for insurance to address all of these, and we don’t have it. A single-payer system addresses none of them.

  17. Sean Says:

    Peris, I think cost is a major problem people have as well. Also the fear of being denied healthcare policy at all. Another major issue is the large number of uninsured.

    A cost comparison table with 6 other countries based on GDP and other comparisons such as % of citizens covered: http://www.npr.org/templates/story/story.php?storyId=110997469

  18. Cathy Says:

    My husband heard a recent interview with a former health insurance exec on NPR. He said the routine process was to deny a claim at first, always, no matter what. Don’t give up…

  19. Stacey Says:

    Last year when I went to the hospital for a routine procedure during pregnancy I was charged for having the baby! I argued on the phone with Humana and the hospital staff that I did NOT give birth and was still pregnant. I had to get a note from my doctor saying so, and they rescinded the fee. I have a copy of the note in my son’s baby book, it is funny. I have heard of people being pregnant and not knowing, but giving birth is something I’d have noticed… I hope this healthcare debacle gets sorted soon too. There are lots of people out there in a terrible situation.

  20. scott Says:

    IN-HUMANA is what i call it

  21. Peris Says:

    Sean, for private insurance, it’s generally true that the more you get, the more you pay, so people pay for and get what they can afford. Being insurance, some (most) people have to pay more than they get back. It really ceases to be insurance if it’s expected to routinely cover routine things that cost more than the beneficiaries and their employers pay in, but that’s what people have grown to expect, and is partly why premiums keep going up so much (whether it should cost $109 to see an MD about a toe is a separate, but very important discussion).

    As for the uninsured, the consensus here seems to be that they aren’t really missing a whole lot.

  22. Sean Says:

    Peris, B’s blog isn’t really the best forum in my opinion for having a debate on healthcare, so I’ll clarify my statement as briefly as I can.

    I’ll also clarify that I posted the bill links not out of endorsement, but because I thought it was a good resource with a line-item commenting system.

    In response to me, you’re talking about insurance company basic economics, but I was referring to was the issue of overall cost to GDP comparisons. I was not strictly referring to insurance costs, this can also be prescription costs etc.

    By being denied a policy I wasn’t referring to being denied procedures if you have a policy. There are many scenarios where a policy can be denied. Where there is Federal oversight, such as transitioning from one group insurance to another there are protections from being denied pre-existing conditions (ex. pregnant woman changing jobs). Most people would agree that this is a good thing, but rarely do they associate it with Gov’t intervention.

    The uninsured who don’t seek preventative care or can’t pay hospital fees effects those that can/do. This issue effects insurance rates and spread of illness, so its not an isolated to a humanitarian cause. Not all uninsured are uninsured by choice, so that alone is worth keeping in mind.

    So I’m fine with having a difference of opinion, and could go on giving personal experiences, but in the scope of things personally I believe healthmcare costs and the uninsured are worthy items to consider on the list of issues people have with health insurance. I was simply saying those 3 points alone were not sufficient in my mind.

  23. Vicky Says:

    Yes, Wendell Potter has said a lot of fun stuff about the insurance industry on NPR and other outlets. You know how I feel about this issue – I’d love our health care to be exactly as it is in France because I’m scared to death to grow old in this country with the current system. My hypothesis is that the insurance companies routinely reject claims and generally run interference – they know most people are not going to pursue claims because they could spend hours on the phone trying to get them straightened out. Most people simply don’t have the time to do that without getting fired.

    My favorite story is about a lump I had under my arm that I was supposed to have looked by a specialist on August 29th, 2005. Needless to say, I didn’t make it to the doctor at Memorial Medical Center. I called my insurance company (Aetna, at the time), and told them I was going to have to start over with tests in Dallas, and they assured me that it was OK – “Go ahead and just take care of yourself,” the woman at Aetna said. Well, when it came time to pay, they didn’t. I called the insurance company and they said that was the final decision, but of course, “I could appeal the decision.” That’s the insurance companies’ favorite line. I was dealing with FEMA, the SBA, and flood insurance already, so didn’t have time to add another fight to my check list.

    The sick thing about it is that our new insurance company sucks even worse than Aetna – we now wish we could have Aetna back! I think that says it all!

  24. Michael Homan Says:

    You should contact Larry C. and Mariam F. about this at Xavier.

  25. judy lindquist Says:

    I am in daily contact with Humana. My physician ordered Celebrex for my sever arthritis. It is listed as a covered drug ion Humana’s formulary. I can not get this drug because they now say it is a step-drug. My physican has to show that I have taken every other arthris medication. Now they will pay for my treatments at a pain center for injections into my spine. They have paid for knee replacements, but not the medication that has worked ( two weeks of drug samples from my physician) That has got to be funny if it didn’t hurt so much!!!!

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