Re: CMS official complaint process

Posted By: Jim DeWees on July 22, 2011

Hello Everyone,

I was the person that posted the email about how to effectively deal with insurance, especially Humana and their "dis-Advantage" plan.

The information I posted was that I contacted the Office of Inspector General's office. I live in Indiana and my local OIG office is in Chicago. I am not sure where all the "local" offices are located in the US, but I think there are several locations for different regions.

This seems to have worked with Humana to get them to FINALLY pay for the claims that were causing me a lot of stress, anger, frustration, etc. Finally, I got to speak with someone at Humana.

Then after I posted the email to you on this listserve, I was contacted out of the blue, from the Director of Provider Relations, asking me if things were resolved, and that he had just gotten some information from someone at Humana informing him of my frustration and problems with Humana, and he was just reaching out to me to see if everything was going ok. He must have gotten this information due to the posting I made here on this listserve. He also asked me to work with him in the future before I file a complaint with the OIG. I told him that would not happen, and that when they make any mistake in the future (which is 100% guarantee), that I will first file it with the OIG again, and not wait for months to file the complaint, and THEN I will work with him to get the situation fixed. I told him the ONLY way that I will not contact the OIG or any other higher level to file complaints is if they don't mess with my claims and unjustly deny them or lose them.

He understood my concerns and was actually a decent person to talk to. I was polite and couteous to him as well, and realize that it is not him personally that does bad things, but he works for a company that makes profits when they make these "mistakes", which makes one wonder how intentional these "mistakes" really are.

Anyway, I would encourage everyone to stay on top of ALL the insurance claims and do NOT just give up and cave in.

On a side note, at a recent class reunion, one of my friends/classmates now works for Anthem/Wellpoint in Indianapolis. He is in the "cost analysis" department, which is where they determine how to increase profits, and how to save money, etc. I had a long conversation with him about specific patient situations and how Anthem has really made their lives more challenging and frustrating. Again, I was not attacking him, but just wanted him to go home and think about how his job is really affecting people that have Anthem insurance. He really couldn't defend his company, but just made sure that I undestand that as long as the providers keep on giving up on some claims, then Anthem will keep on denying them because they know that this is going to save them up to 40% due to doctors and providers just giving up, or forgetting about these claims.

He told me that once they end up paying out something like 90% of these "denied claims", then Anthem will realize that they are just paying more people to look at these claims over and over and over again, and that is costing them money, because eventually they will end up paying these out anyway. So, once the providers keep fighting them, then that ties up their employees and that costs the insurance comapnies money. Then, when they realize how much they are wasting trying to not pay these claims, they will stop that practice. (But, they will probably find something worse to do at that point!!)

Also, another thing that I do now, is when I have to fill out a form, or take time out of MY life to fix a problem that someone else created, I get this company on the phone, and then I make sure that I tie that person up and make that person sit on the phone with me while I fill out the form, or complete the online form, whatever the case. I had a woman on the phone with me for 45 minutes the other day, while I filled out a Medicare form (they didn't pay for the prosthetic leg because she was in a Skilled Nursing Facility at the time of service.....I didn't know that she was in a nursing home, she didn't mention that to me, and her son that drove her here didn't mention that either...BUT that didn't matter, because the procedure codes...L-codes....are NOT on the list of "coordinated benefits for SNF's"). Anyway this woman verified that these codes are NOT on the list and they SHOULD have been paid...and so I had to fill out the form and fax it to them to have it re-evaluated. I kept her on the phone the entire time to make sure I filled out every single space necessary. She kept on saying that she had to go, that she can't be on the phone calls this long, and I told her that I don't have the time to fix THEIR mistakes either, and so if I am going to spend MY time fixing this mistake, the SHE can sit on the phone with me too. OR she can figure out a way to push the magic button on her computer that will generate this claim to just reprocess and save us BOTH the time that is being wasted due to THEIR error.

Anyway, if we ALL take up more of their time fixing THEIR mistakes, they will find that they need to hire MORE phone help to field all these issues, and maybe realize that they are spending more money than they should to address these problems, and maybe they will figure out how to reduce these problems. They just can't afford to have customer service lines that have long wait times. If that is the case, they will lose their chances at government contracts if their customer support is rated really badly.

These are just some little ideas that I have to deal with these horrible insurance situations. Maybe they are petty and stupid, but that is usually how things change, when people take actions that end up costing these companies money that cuts into their bottom lines.

But at least I feel better when I know I have inconvenienced someone that is inconveniencing me. I know that she was annoyed by staying on the phone with me, but I was also annoyed that I even had to be on the phone with her at all.

Just some thoughts......

Take care, and have a great weekend, and stay cool (it is already in the 90's here this morning....yuck!!!)

Jim DeWees, CP


> Date: Thu, 21 Jul 2011 14:28:30 -0400
> From: [E-mail Address Removed]
> Subject: [OANDP-L] CMS official complaint process
> To: [E-mail Address Removed]
>
> Several months ago (or more!) someone posted a process that they used that
> got the attention of Humana as a Medicare provider in order for them to pay
> a legitimate claim for a Medicare beneficiary who had opted to use Humana
> as their provider. We continue to be bullied by Humana for legitimate
> claims and would like to pursue a process of registering a complaint with CMS.
> If anyone can refer me to the prior post or add insight, I would
> appreciate any help.
> Thanks
> Jerry Nelson CPO
>
>
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