Humana is notifying physicians across Texas that is it kicking them out of Humana's Medicare Advantage (MA) PPO and/or Preferred PPO/Preferred Point of Service networks as of Aug. 1.
Federal regulations require Humana and other insurers to give physicians due process prior to a "for cause" deselection from an MA PPO. The Humana letter describes an abbreviated paper review process. Consider discussing with your legal counsel the advisability of requesting in writing a due process hearing to challenge the deselection from the Humana MA PPO.
The notices do not provide specific patient information or claims details that Humana used in deciding to terminate the physician or group. Without this information, it is virtually impossible for physicians to effectively appeal the decision, says TMA General Counsel Donald "Rocky" Wilcox, JD. Request all relevant information, including individual patient data used to determine accuracy, and explain why tests were or were not done.
TMA is tracking this issue. If you are considering filing an appeal, send a copy to Liz Jero in the TMA Payment Advocacy Department and notify her of any resolution or issues that occur.
State law requires health plans that involve insured products to have a review process by a panel of physicians before a deselection decision and before patients are notified that their doctor has been removed from the network.
TMA has compiled this information about appealing deselection or challenging rating decisions by insurers:
- Review your contract. Does the insurer have the right to profile physicians and restrict their access to patients? Does the contract specify the appeal mechanism or other rights with respect to profiling or tiering? Make sure you do not miss any deadlines.
- Request a complete copy of your profile, profiling methodology, and the data used. If the insurer does not respond, ask again. Do not accept incomplete information or data from the insurer. You should receive a complete analysis of the data and the system used to determine your rating.
- Review your profile report carefully. Pay attention to the number of cases used to determine your rating. Small sample sizes are the single biggest cause of inaccurate ratings. Compare the data referenced in the report with your actual claims/chart data. Is the insurer using another physician's data or missing vital information? Are there valid reasons for your practice variation? Examine your data for outlier cases, severity of illness, comorbidities, unusual demographics, and patient compliance problems. Insurers' risk adjustment systems are often minimal, and expert opinions indicate that all are inadequate. None adjust for educational or economic status of patients.
- Contact TMA, your county society, or the American Medical Association if you are unsuccessful in your attempts to reconcile your rating.
- If you file a timely appeal within the deadlines, you should be able to stay in the insurance company's network pending the appeal.
Humana's MA PPO notices state that:
- Humana had reevaluated and is reducing the size of its MA network, while maintaining or exceeding Centers for Medicare & Medicaid Services standards.
- The evaluation included a review of the physician's efficiency using a claims-based, episode-of-care methodology.
- Humana also took into consideration MA PPO network access requirements, practice specialty needs, and geographic factors.
- Physicians can ask an advisory board to review the decision if they submit a written request within 30 calendar days of receiving the notice and include any written information to be considered in the review.
- They have the right to object to the amendment within 90 days via a written request.
The Humana Preferred PPO and Humana Preferred Point of Service Open Access Notice says:
- Humana created the products based on customer demand for lower costs.
- A physician's participation was determined based on industry-standard, episode-of-care methodology based on inpatient, outpatient, ambulatory, and pharmacy claims data, and adjusted for severity and geography.
- Physicians can have an advisory panel review the decision under Texas Department of Insurance regulations if they submit a written request within 14 calendar days of receiving the notice. Physicians can submit supporting documentation for the review within 28 calendar days.
- They also have the right to request an expedited review by submitting a written request within seven calendar days of receiving the notice and submitting supporting documentation within 14 calendar days.
For more information regarding problems with network deselection or ratings, call TMA's Knowledge Center at (800) 880-7955, or e-mail TMA Knowledge Center .
Action , June 3, 2009