Humana notified about 200 Texas physicians it is removing them from its Medicare Advantage network on Jan. 1. Humana began sending letters to physicians on June 1 telling them that claims data indicate their practices do not meet its cost and/or quality measures.
TMA's Payment Advocacy Department advises you to act immediately if you get a termination letter because you have only 14 days to appeal after the letter arrives. You must send the appeal letter to Humana by certified mail or other method that can be tracked.
Humana sent the termination letters via UPS, thus physicians should be on alert for any Humana correspondence.
The letters, which Humana says the Centers for Medicare & Medicaid Services approved, do not include patient-specific claims data that physicians can review; they must contact Humana and ask for the information.
Humana's Medicare Advantage Rules of Participation outlines how Humana measures physicians.
TMA offers these tips for physicians getting a termination letter:
- Make an immediate, clear request for your reports and patient-specific information so you can review it for accuracy. This information is vital; without it an appeal is almost impossible.
- You request the data by calling the telephone number on the letter. Humana says physicians should be able to receive the requested data by fax and/or email within one business day. If you choose email, be sure to check your spam filter as well as your inbox.
- The appeal must include documentation that you feel Humana should consider in your appeal; Humana will not consider it without documentation.
- If you have a subspecialty, make sure you notify Humana of this to ensure that it is comparing your claims data to the appropriate specialty.
- Physicians can request a doctor-to-doctor conversation about the termination with a Humana medical director.
TMA is tracking this issue. If you appeal, please email a copy to Liz Jero in Payment Advocacy or fax it to her at (512) 370-1632 and let her know the outcome. Due to HIPAA, do not send any protected health information via email.
TMA cannot appeal for you but can answer general questions.
TMA developed a white paper outlining your rights if an insurance plan terminates you from your network.
Action, June 15, 2012
Last Updated On
August 01, 2016