CHRONIC TONIC posts on Thursdays at 7 EST, it is a place to share stories, advice, and information and to connect with others with chronic health conditions and those who care for them. Our diarists will report on research, alternative treatments, clinical trials, and health insurance issues through personal stories. You are invited to share in comments (and note if you'd like to be a future diarist). In addition to our weekly diaries, please join us for ongoing conversations at the Kossacks Networking site.
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Today's diarist: MsGrin
Neuropsychological tests are evaluations designed to determine the functional consequences of known or suspected brain injury through testing of the neurocognitive domains responsible for language, perception, memory, learning, problem solving, adaptation, and constructional praxis.
These tests are carried out on patients who have suffered neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. They are objective and quantitative in nature and require patients to directly demonstrate their level of competence in a particular cognitive domain...when used judiciously in patients with particular neuropsychologic problems, they can be an important tool in making specific diagnoses or prognoses after neurologic injury, to aid in treatment planning, and to address questions regarding treatment goals, efficacy, and patient disposition.
Everyone on this site will understand the political use of non-denial, denials where someone tries to weasel their way out of blame by perhaps obliquly acknowledging that mistakes were made, while avoid taking direct responsibiity.
There's a different twist for health insurance: the denial denial. In this particular case, a denial of coverage happened in substantial part, but the language sent in the letter describing the outcome of the reconsideration stated that the denial had been reversed...only it hadn't. In fact, if anything, the new outcome was even less in favor of the member.
"After careful review, Humana determined to overturn the original denial and pay the claim."
Only, they really didn't.
The payment at issue was about neurocognitive testing. The provider was out of network. A similar previous test which took 4 hours and resulted in a report of three pages by an in-network provider garnered that person a fee of roughly $500.
This round of testing was designed to fill in holes the previous test missed, so it was comprised of 10 hours of testing and a 20 page report. For this including several hours of review of medical records the provider billed $1800 for a total of 16 hours work.
Humana wrote a check to the member for less than half of what the first guy got paid. The member phoned to learn why it was that more than twice as much work was paid at less than half the fee of the previous testing, and there was some unclear mumbling about this being 'mental health treatment' getting paid at a lower rate. Only this wasn't treatment, it was assessment, and while these tests do some psychological evaluation, they are primarily looking at neurological issues (see above).
The member returned the check and asked for reconsideration to include explanation of the disparity between payment on the two sets of testing as well as how it was determined that this testing was now 'treatment' as opposed to 'assessment' and why that meant it would be covered at a lower rate. In the letter, the member pointed out that further proof that the payment was in error is that the insurance company forgot to factor in the member's deductible for using an out of network provider.
The new explanation of benefits (EOB) arrived before the letter. Two things changed, Humana decided that the service was now worth $40 moore than it had been previously, and they now said that the payment should come out of the member's deductible, meaning that Humana is no longer responsible for any payment.
The member next received a demand to return the monies previously sent - but of course the member had returned the uncashed check with the request for reconsideration.
Every EOB form comes with directions about how to file an appeal/request for reconsideration. That form also says that after going through that process, that Medicare will offer an independent review if the member hasn't received what they believed was due.
It turns out that there are several more stages of dispute resolution which lead eventually to federal court. The first step is the reconsideration by the insurance company, and if the insurance company affirms their adverse decision, the insurance company is required to automatically forward the file to a federal contractor for this independent review which is the second step.
The manual for Medicare Advantage plans says this about insurance companies doing this automatic forwarding:
If CMS determines that the Medicare health plan has a pattern of not making a reasonable and diligent effort to gather and forward information to the independent review entity, the Medicare health plan will be considered to be in breach of its Medicare contract.
So, is the letter saying that Humana reversed itself (when clearly it did not) meant to protect them from getting busted in an audit? Certainly, it keeps members from being apprised of their rights.
Anyone else seen this sort of denial-denial?
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