Horror story with Humana

General Discussion on any topic relating to CPAP and/or Sleep Apnea.

Horror story with Humana

Post by MorefromHopeful » Wed Jun 15, 2005 11:16 am

Well, folks, haven't visited in a while, I've been happily snoring away with my machine...

Just wanted to share with you a particularly gruesome insurance story, perhaps some of you will benefit by it.

I bought my CPAP machine directly from CPAP.com. According to my Humana group policy, it was covered 50% as an out-of-network expense, costing about $ 1050 with all of the bells and whistles (mask, etc.)

I realized that renting would be more expensive than buying direct, since I had a $ 250 deductible and it would go over a year to pay for the machine. Plus, I hated the equipment vendor and was happy to get rid of them after a few days renting.

Well, I submitted my claim to Humana in February. Here's their complete list of tactics they used to avoid paying the legitimate claim:

1) They accepted only mail claims. Believe it or not, the entire Humana claims department does not own one single fax. Strangely enough, they lost both of the mailed claims. The only way I was able to mail the claim in was to fax the claim into the general 1-800 number, and THEY then MAILED it into their OWN CLAIMS DEPARTMENT (I KID YOU NOT!!). By the time this happened, 2 months had gone by (we are at end of April).

2) They processed the claim incorrectly, denying because the codes were incorrect. I corrected the codes via a phone call with the knowledgeable, helpful people at CPAP.com. Another 21 day wait for "processing"

3) They finally deny the claim on the grounds that, despite my physician writing a prescription, the equipment was not pre-authorized. Note that during the entire time I was speaking to many individuals about the process I needed to go through, none of the mentioned the tiny fact that the equipment purchase needed to be pre-authorized.

UPSHOT - BUY EQUIPMENT ONLY THROUGH A DOCTOR IF POSSIBLE -- let them wrangle their way through the insurance morass.

Humana paid for the sleep study no problem, much more expensive. I guess because I'm not a provider, I'm just chop liver.

Cheerful though pissed off --



Sorry -- my deductible was $ 500 a year, not $ 250 a year

Post by MorefromHopeful » Wed Jun 15, 2005 11:18 am

Otherwise it doensn't make sense!

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Re: Horror story with Humana

Post by forumadmin » Wed Jun 15, 2005 12:34 pm

MorefromHopeful wrote: 2) They processed the claim incorrectly, denying because the codes were incorrect. I corrected the codes via a phone call with the knowledgeable, helpful people at CPAP.com. Another 21 day wait for "processing"
Which code was wrong?!


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Post by DME » Wed Jun 15, 2005 1:06 pm

Hopeful. This is what DME's go through. Insurance companies can always find a way not to pay. This is why DME's employ an insurance verifier and a billing/collections specialist. These people are not cheap. If DME's could operate like the internet business's (cash and carry) their prices would be much cheaper. One good thing to note is that this forum is working on the proper procedure for submitting claims to the insurance provider.

By the way, you mention all this time and effort you spent on trying to collect your cash from Humana. It usually takes DME's anywhere from 30-90 days to collect on services performed. Your one person, imagine trying to fight for your money on 100 patients a month. DME is not such a lucrative business.

Thanks for your story. I hope some people can realize one of the reasons DME's need to charge a higher price than the internet. We need to pay for two trained people to verify, bill and collect not to mention an RT to provide education and fitting. I do agree that some of the prices I have seen and heard about are excessive and I would agree that those DME's are evil.

I know we are a DME that many of you first timers would love, and not have to battle the insurace provider. HMMM maybe they are the evil creating the evil.


In response to the question...

Post by MorefromHopeful » Wed Jun 15, 2005 6:35 pm

The code that was incorrect was the procedure or diagnosis code. In my case, Humana rejected it the first time because they were unfamiliar with the CPAP machine code, and were treating it like a service or medical procedure.

This may still be the case. At any rate, they have finally, after 5 months, worn me down. They may have my $ 450 and may they never have a day's luck with it!

Regarding DME's, anyone who deals with these insurance companies have my complete sympathy. My DME was kind and well meaning but 1) completely unknowledgeabe about sleep apnea other than the rudiments of snapping the machine together; 2) inflexible (when I needed help, which was during the weekend and at night, no one was there); and 3) charging an awful lot for this so-called service.

It has not escaped me that while individuals have an uphill battle getting reimbursed, providers like the sleep clinic seem to get their pay rapidly and easily. Certainly that was true for my sleep study.

My advice -- find a sympathetic doctor -- have them order you the machine of your choice -- pay them and have them bill the danged insurance company. I believe if I had taken this route, I'd have the machine of my choice (unavailable through my DME) as well as my money back!