A Most Unfortunate Advantage Plan Journey
I’m going to start with the lessons from today’s video. First, understand that Advantage Plans have provider networks and you may be referred to a facility you would not choose. Second, if you arrange to be self-pay at an in-network facility of your choice without the plan’s approval and intend to appeal that, understand the process will likely be long and arduous.
Our client needed inpatient rehab, but her Humana Advantage Plan referred her to a facility she felt was subpar due to past experiences there. To avoid another subpar experience, she chose to self-refer to a different, yet also in-network, rehab facility even though she did not have the plan’s approval to go there.
Because she didn’t have the plan’s prior approval, the client paid the rehabilitation hospital upfront to secure same-day admission. Surprisingly, Humana subsequently paid the claim in a fairly timely fashion but then retracted the payment. We can’t know why. It might have been an automated process for retracting payment when an authorization is not in the system. She planned to, and did, appeal the denial of her stay – but that was unsuccessful.
In our opinion, Humana should have paid. After all, our client had been referred to another facility which underscored medical necessity. We filed a second appeal which was successful, the Plan paid a second time, and we expected a timely refund to our client. That didn’t happen.
I got involved when matters seemed stuck. The rehab hospital is part of what may be the largest provider of inpatient rehab services in the country, Encompass, formerly Health South. I was able to speak to an individual with the title of Controller at the facility where our client was treated who was able to confirm that a refund wasn’t planned because Humana had notified them that they planned to retract the second payment. I would have to speak to corporate.
Before doing so, I called Humana. I was on the phone for thirty minutes while the rep searched for the claim. That was odd. She couldn’t provide any information about why the claim payment was going to be retracted. I’ve never heard of a claim being retracted after a successful appeal; appeals involve more scrutiny than routine claims.
One of my colleagues searched the internet to determine the likely email format for corporate executives and identified two high level people in Finance to whom I sent emails asking for help. This was a Friday afternoon and on Monday morning I got a call back from an Encompass person charged with working with us. She couldn’t explain why Humana planned to retract the claim but confirmed that information was in their system with even the date the payment would be retracted. After our discussion, she communicated with her contacts at Humana who said they had no record of a successful appeal.
WHAT?
That information was easy for us to provide and Humana immediately backed off, indicating they would NOT retract the claim.
I received an email from our new friends at Encompass earlier today (March 26, 2027) which indicated the refund to our client is in process.
The unfortunate fact is that our client would probably have never had coverage or received a refund without our help. That’s a disgrace.
And please remember, this never would have happened to someone on original Medicare.
