Has Humana approved or rejected your appeal of the company's decisions to remove you from its Medicare Advantage (MA) PPO and/or Preferred PPO/Preferred Point of Service networks? Have you received a letter from Health Research Insights (HRI) demanding recoupment of overpayments caused by "incorrect claims."
TMA is monitoring both of these situations very closely.
Please e-mail Liz Jero if you have heard from Humana. If you have received an HRI letter, please e-mail a copy to Erin Gregorcyk or fax it to her at (512) 370-1693.
Humana has begun ruling on physician appeals. It announced earlier this year it would remove physicians who did not meet its "access requirements" or "efficiency threshold" from its networks starting Aug. 1. 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 notifying patients that their doctor has been removed from the network. Federal regulations require Humana and other insurers to give physicians a description of the reasons for terminating the contract, along with an opportunity to appeal the deselection from the MA PPO network.
As for HRI, TMA is trying to determine the extent of the company's activities, if any, in Texas. Large, self-insured companies are hiring the company to examine their employees' claims for payment errors. The company's actions created controversy in Tennessee, and the state medical association there is suing the company.
Action , Aug. 17, 2009
Last Updated On
May 13, 2016
Originally Published On
March 23, 2010