Guest guest Posted September 6, 2009 Report Share Posted September 6, 2009 Ellen,Apparently becoming a "deemed contractor" has nothing to do with any signed contract. It appears to be permitted by a special regulation of Medicare. According to this Medicare publication:Deemed—Providers are “deemed” when they know, before providing a service, that you are in a Medicare Private Fee-for-Service Plan; they have reasonable access to the plan’s terms and conditions of payment; and the service is covered by the plan. Providers that are “deemed” agree to follow your plan’s terms and conditions of payment for the services you get. http://www.medicare.gov/Publications/Pubs/pdf/10144.pdfThis is from the MGMA web site:A provider has "reasonable access" to the plan's terms and conditions of payment if theplan makes accessible its terms and conditions of payment through:MailE-mailFaxTelephoneA plan Web siteIt is then the provider's responsibility to call or fax the PFFS plan or to visit the PFFS Web site to obtain the plan's conditions of participation. However, announcements in newspapers, journals, or magazines or on radio or television are not considered communication of the terms and conditions of payment.It is important to emphasize that although a provider who does not have a direct contract with the plan may choose to provide, or not to provide services, the provider does not have the option of becoming non-contracting. Rather, once the provider provides services, the provider automatically becomes deemed-contracting provided the deeming conditions listed above have been met.Any provider who was aware in advance of furnishing services, that the person receiving the services is enrolled in the PFFS plan and had reasonable access to the plan's terms and conditions of payment becomes a deemed contracting provider for the services they furnish that enrollee.http://www.mgma.com/policy/default.aspx?id=18732Click on the links for more info. Bottom line: if you don't want to be a "deemed contractor", don't accept or see Medicare Advantage patients. SetoSouth Pasadena, CANothing like this is in the contract I recently received. I doubt whether anything stated as below could be legal. Why would insurance or any of us bother with any contracts if this were true? If you are not on an insurance panel, then your care should be out of network for that pt. I have a few pts who see me out of network and they have to pay more out of pocket. I have nothing pro/con to say about Humanaas I have no experience with them but what you have written is not as a "direct quote" and you also say it was from a couple of years ago. I think we ought to be careful what we put out to everyoneas fact. EllenCarla Gibson wrote:> > I did not contract with Humana- I simply saw Humana Gold Choice > patients... If you see the patient, then you are agreeing to the terms > they offer. This is from a Humana Brochure and similar to what I > remember reading from one of their letters a couple of years ago:>> What is a participating provider?> A participating provider is a physician or other health> care provider who knows of a member's enrollment in a> Humana MA PFFS plan and has been given a reasonable> opportunity to obtain the terms and conditions for> payment for services provided to a Humana MA PFFS> plan enrollee. Physicians and other health care providers> must be licensed and must be eligible to provide care> to Medicare-eligible patients, with no sanctions against> their licensure. If a physician or health care provider> renders care to a Humana MA PFFS plan member,> the physician or health care provider is considered> participating for that member. For a copy of our full> terms and conditions, please call Provider> Relations at 1-.> Does the physician have a responsibility> to somehow notify the plan that he or she> is participating?> No. There are no contracts to sign, and there is no> paperwork required to participate. The physician or> other health care provider simply needs to see the> member's ID card to identify the individual as a Humana> MA PFFS plan member. The physician or other health> care provider should review the terms and conditions of> payment. If the provider renders care to the member,> that provider is participating. A physician or other> health care provider may choose to provide care to> Humana MA PFFS plan enrollees on a patient-by-patient> basis and may stop treating enrollees at any time.>> Carla Gibson FNP> Missoula, MT>> ----------------------------------------------------------> *From:* Robbins Health Alliance <robbinshealth>> *To:* > *Sent:* Thursday, September 3, 2009 9:35:41 PM> *Subject:* Re: Scoop on Humana>> >> that's exactly why I refuse to accept Humana>> The Robbins Health Alliance> 1324 Rockbridge Road, SW> Stone Mountain, GA 30087> PH: > Fax: > www.robbinshealth. com <http://www.robbinshealth.com>> Your first choice for Internal and Holistic Medicine.>>> > >> >> > Humana has just moved to town and has sent me a contract. I> > cherry-pick my insurance companies and generally only> contract with> > those that treat physicians well, meaning reasonable> reimbursement> > along with minimal hassles. Does anyone know how Humana> is with> > respect to promptness of payment, refusing to pay for> technicalities,> > requiring chart notes and documentation, requiring lots> of pre-auths> > and paperwork for drugs/studies, etc?> >> > Thanks!> > Jen Wallace> >> >>>> ---------------------------------------------------------->>>> <nellegreen.vcf> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 6, 2009 Report Share Posted September 6, 2009 Ellen:A couple of years ago I rec'd a letter from Humana explaining this. I assume they sent it to all Medicare providers?? The text re: What is a participating provider is a cut and paste from the Humana brochure currently on their website. I don't interpret it to say I have to take that patient - I can pick and choose, as I read it. But I do interpret it as saying that if I see them, I agree to their terms for payment (as I have not opted out of Medicare). Seto has the resources re: how it works if you have opted out. If you have a signed contract with Humana, that seems like a different beast. I am treated as non-participating for the rare non-Medicare Humana patient I see.Re: the original question about sending records is an easy fix- charge them or tell them to come get them. I find it very easy to fax my records from my EMR but will starting requesting payment prior to faxing from now on.Carla Gibson FNPTo: Sent: Sunday, September 6, 2009 9:11:09 AMSubject: Re: Scoop on Humana Nothing like this is in the contract I recently received. I doubt whether anything stated as below could be legal. Why would insurance or any of us bother with any contracts if this were true? If you are not on an insurance panel, then your care should be out of network for that pt. I have a few pts who see me out of network and they have to pay more out of pocket. I have nothing pro/con to say about Humana as I have no experience with them but what you have written is not as a "direct quote" and you also say it was from a couple of years ago. I think we ought to be careful what we put out to everyone as fact. Ellen Carla Gibson wrote: > > I did not contract with Humana- I simply saw Humana Gold Choice > patients... If you see the patient, then you are agreeing to the terms > they offer. This is from a Humana Brochure and similar to what I > remember reading from one of their letters a couple of years ago: > > What is a participating provider? > A participating provider is a physician or other health > care provider who knows of a member's enrollment in a > Humana MA PFFS plan and has been given a reasonable > opportunity to obtain the terms and conditions for > payment for services provided to a Humana MA PFFS > plan enrollee. Physicians and other health care providers > must be licensed and must be eligible to provide care > to Medicare-eligible patients, with no sanctions against > their licensure. If a physician or health care provider > renders care to a Humana MA PFFS plan member, > the physician or health care provider is considered > participating for that member. For a copy of our full > terms and conditions, please call Provider > Relations at 1-. > Does the physician have a responsibility > to somehow notify the plan that he or she > is participating? > No. There are no contracts to sign, and there is no > paperwork required to participate. The physician or > other health care provider simply needs to see the > member's ID card to identify the individual as a Humana > MA PFFS plan member. The physician or other health > care provider should review the terms and conditions of > payment. If the provider renders care to the member, > that provider is participating. A physician or other > health care provider may choose to provide care to > Humana MA PFFS plan enrollees on a patient-by-patient > basis and may stop treating enrollees at any time. > > Carla Gibson FNP > Missoula, MT > > ------------ --------- --------- --------- --------- --------- - > *From:* Robbins Health Alliance <robbinshealth@ yahoo.com> > *To:* Practiceimprovement 1yahoogroups (DOT) com > *Sent:* Thursday, September 3, 2009 9:35:41 PM > *Subject:* Re: [Practiceimprovemen t1] Scoop on Humana > > > > that's exactly why I refuse to accept Humana > > The Robbins Health Alliance > 1324 Rockbridge Road, SW > Stone Mountain, GA 30087 > PH: > Fax: > www.robbinshealth. com <http://www.robbinsh ealth.com> > Your first choice for Internal and Holistic Medicine. > > > > > > > > > Humana has just moved to town and has sent me a contract. I > > cherry-pick my insurance companies and generally only > contract with > > those that treat physicians well, meaning reasonable > reimbursement > > along with minimal hassles. Does anyone know how Humana > is with > > respect to promptness of payment, refusing to pay for > technicalities, > > requiring chart notes and documentation, requiring lots > of pre-auths > > and paperwork for drugs/studies, etc? > > > > Thanks! > > Jen Wallace > > > > > > > ------------ --------- --------- --------- --------- --------- - > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 6, 2009 Report Share Posted September 6, 2009 I think this is true for all of the Medicare Advantage plans. If you see the patient and agree to submit a claim for them, then you are bound by the contract, but only for that patient. You do not have to agree to take any other patients under that plan. If you’re not participating with Medicare, then I would probably avoid the Medicare PFFS plans altogether. Pratt Office Manager Oak Tree Internal Medicine P.C www.prattmd.info From: [mailto: ] On Behalf Of Pierce Sent: Friday, September 04, 2009 4:23 AM To: Subject: Re: Scoop on Humana Apparently many, if not all , of the Medicare Advantage carriers do this: http://www.mgma.com/policy/default.aspx?id=18732 Can this be enforced if the physician has opted out of Medicare? R. Pierce MD Rockport, Maine www.midcoastmedicine.com Carla Gibson wrote: > > I did not contract with Humana- I simply saw Humana Gold Choice > patients... If you see the patient, then you are agreeing to the terms > they offer. This is from a Humana Brochure and similar to what I > remember reading from one of their letters a couple of years ago: > > What is a participating provider? > A participating provider is a physician or other health > care provider who knows of a member's enrollment in a > Humana MA PFFS plan and has been given a reasonable > opportunity to obtain the terms and conditions for > payment for services provided to a Humana MA PFFS > plan enrollee. Physicians and other health care providers > must be licensed and must be eligible to provide care > to Medicare-eligible patients, with no sanctions against > their licensure. If a physician or health care provider > renders care to a Humana MA PFFS plan member, > the physician or health care provider is considered > participating for that member. For a copy of our full > terms and conditions, please call Provider > Relations at 1-. > Does the physician have a responsibility > to somehow notify the plan that he or she > is participating? > No. There are no contracts to sign, and there is no > paperwork required to participate. The physician or > other health care provider simply needs to see the > member's ID card to identify the individual as a Humana > MA PFFS plan member. The physician or other health > care provider should review the terms and conditions of > payment. If the provider renders care to the member, > that provider is participating. A physician or other > health care provider may choose to provide care to > Humana MA PFFS plan enrollees on a patient-by-patient > basis and may stop treating enrollees at any time. > > Carla Gibson FNP > Missoula, MT > > ---------------------------------------------------------- > *From:* Robbins Health Alliance <robbinshealth> > *To:* > *Sent:* Thursday, September 3, 2009 9:35:41 PM > *Subject:* Re: Scoop on Humana > > > > that's exactly why I refuse to accept Humana > > The Robbins Health Alliance > 1324 Rockbridge Road, SW > Stone Mountain, GA 30087 > PH: > Fax: > www.robbinshealth. com <http://www.robbinshealth.com> > Your first choice for Internal and Holistic Medicine. > > > > > > > > > Humana has just moved to town and has sent me a contract. I > > cherry-pick my insurance companies and generally only > contract with > > those that treat physicians well, meaning reasonable > reimbursement > > along with minimal hassles. Does anyone know how Humana > is with > > respect to promptness of payment, refusing to pay for > technicalities, > > requiring chart notes and documentation, requiring lots > of pre-auths > > and paperwork for drugs/studies, etc? > > > > Thanks! > > Jen Wallace > > > > > > > ---------------------------------------------------------- > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 7, 2009 Report Share Posted September 7, 2009 --- Thanks for the information. But I thought that was providing 'direct service' which meant that she was going outside the insurance industry and charging pts directly and not expecting Medicare/any insurance to be involved. If that is the case, then the pt made the choice to submit her bill to insurance and it would be the pt's responsibility(??). Otherwise, I don't know what the point of such 'direct service' is other than the provider not doing the insurance billing. I would think that pts should be made aware of things that can happen if they submit their own bills. And even if the pt did submit the bill to insurance and the provider agreed to provide chart notes, isn't the pt paying cash up front? Please clarify. Thanks. Ellen Seto wrote: > > Ellen, > > Apparently becoming a " deemed contractor " has nothing to do with any > signed contract. It appears to be permitted by a special regulation of > Medicare. According to this Medicare publication: >> Deemed—Providers are “deemed” when they know, before providing a >> service, that you are in a Medicare Private Fee-for-Service Plan; >> they have reasonable access to the plan’s terms and conditions of >> payment; and the service is covered by the plan. Providers that are >> “deemed” agree to follow your plan’s terms and conditions of payment >> for the services you get. > > http://www.medicare.gov/Publications/Pubs/pdf/10144.pdf > <http://www.medicare.gov/Publications/Pubs/pdf/10144.pdf> > > This is from the MGMA web site: > >> A provider has " reasonable access " to the plan's terms and conditions >> of payment if the >> plan makes accessible its terms and conditions of payment through: >> >> * Mail >> * E-mail >> * Fax >> * Telephone >> * A plan Web site >> >> It is then the provider's responsibility to call or fax the PFFS plan >> or to visit the PFFS Web site to obtain the plan's conditions of >> participation. However, announcements in newspapers, journals, or >> magazines or on radio or television are not considered communication >> of the terms and conditions of payment. >> >> It is important to emphasize that although a provider who does not >> have a *direct contract* with the plan may choose to provide, or not >> to provide services, the provider does not have the option of >> becoming *non-contracting.* Rather, once the provider provides >> services, the provider automatically becomes *deemed-contracting* >> provided the deeming conditions listed above have been met. >> >> Any provider who was aware in advance of furnishing services, that >> the person receiving the services is enrolled in the PFFS plan and >> had reasonable access to the plan's terms and conditions of payment >> *becomes a deemed contracting provider* for the services they furnish >> _that enrollee_. >> > http://www.mgma.com/policy/default.aspx?id=18732 > <http://www.mgma.com/policy/default.aspx?id=18732> > > Click on the links for more info. Bottom line: if you don't want to be > a " deemed contractor " , don't accept or see Medicare Advantage patients. > > Seto > South Pasadena, CA > > > >> Nothing like this is in the contract I recently received. I doubt >> whether anything stated as below could be legal. Why would insurance or >> any of us bother with any contracts if this were true? If you are not on >> an insurance panel, then your care should be out of network for that >> pt. I have a few pts who see me out of network and they have to pay >> more out of pocket. I have nothing pro/con to say about Humana >> as I have no experience with them but what you have written is not as a >> " direct quote " and you also say it was from a couple of years ago. I >> think we ought to be careful what we put out to everyone >> as fact. >> >> Ellen >> >> Carla Gibson wrote: >> > >> > I did not contract with Humana- I simply saw Humana Gold Choice >> > patients... If you see the patient, then you are agreeing to the terms >> > they offer. This is from a Humana Brochure and similar to what I >> > remember reading from one of their letters a couple of years ago: >> > >> > What is a participating provider? >> > A participating provider is a physician or other health >> > care provider who knows of a member's enrollment in a >> > Humana MA PFFS plan and has been given a reasonable >> > opportunity to obtain the terms and conditions for >> > payment for services provided to a Humana MA PFFS >> > plan enrollee. Physicians and other health care providers >> > must be licensed and must be eligible to provide care >> > to Medicare-eligible patients, with no sanctions against >> > their licensure. If a physician or health care provider >> > renders care to a Humana MA PFFS plan member, >> > the physician or health care provider is considered >> > participating for that member. For a copy of our full >> > terms and conditions, please call Provider >> > Relations at 1-. >> > Does the physician have a responsibility >> > to somehow notify the plan that he or she >> > is participating? >> > No. There are no contracts to sign, and there is no >> > paperwork required to participate. The physician or >> > other health care provider simply needs to see the >> > member's ID card to identify the individual as a Humana >> > MA PFFS plan member. The physician or other health >> > care provider should review the terms and conditions of >> > payment. If the provider renders care to the member, >> > that provider is participating. A physician or other >> > health care provider may choose to provide care to >> > Humana MA PFFS plan enrollees on a patient-by-patient >> > basis and may stop treating enrollees at any time. >> > >> > Carla Gibson FNP >> > Missoula, MT >> > >> > ---------------------------------------------------------- >> > *From:* Robbins Health Alliance <robbinshealth@... >> <mailto:robbinshealth%40yahoo.com>> >> > *To:* >> <mailto:%40yahoogroups.com> >> > *Sent:* Thursday, September 3, 2009 9:35:41 PM >> > *Subject:* Re: Scoop on Humana >> > >> > >> > >> > that's exactly why I refuse to accept Humana >> > >> > The Robbins Health Alliance >> > 1324 Rockbridge Road, SW >> > Stone Mountain, GA 30087 >> > PH: >> > Fax: >> > www.robbinshealth. com <http://www.robbinshealth.com >> <http://www.robbinshealth.com>> >> > Your first choice for Internal and Holistic Medicine. >> > >> > >> > >> > > >> > > >> > > Humana has just moved to town and has sent me a contract. I >> > > cherry-pick my insurance companies and generally only >> > contract with >> > > those that treat physicians well, meaning reasonable >> > reimbursement >> > > along with minimal hassles. Does anyone know how Humana >> > is with >> > > respect to promptness of payment, refusing to pay for >> > technicalities, >> > > requiring chart notes and documentation, requiring lots >> > of pre-auths >> > > and paperwork for drugs/studies, etc? >> > > >> > > Thanks! >> > > Jen Wallace >> > > >> > > >> > >> > >> > ---------------------------------------------------------- >> > >> > >> > >> > >> >> <nellegreen.vcf> > > Attachment: vcard [not shown] Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 7, 2009 Report Share Posted September 7, 2009 Carla--- Thanks for clarifying where your info came from. It does seem that if you do agree to see a pt with a certain insurance and expect to be paid by that insurance, then you also agree to their terms. Most insurance companies won't pay a non-contracting provider or will pay them as out of network. That is why most providers/MDs don't see pts who have insurance with whom they do not have a contract. You can't have it both ways. If you don't like how they treat you as a non-par provider, then you shouldn't see those pts. As I said, specialists in my area won't see Medicare pts if they do not have a contract with their Medicare plan, as I won't. Ellen Carla Gibson wrote: > > Ellen: > > A couple of years ago I rec'd a letter from Humana explaining this. I > assume they sent it to all Medicare providers?? The text re: What is > a participating provider is a cut and paste from the Humana brochure > currently on their website. I don't interpret it to say I have to > take that patient - I can pick and choose, as I read it. But I do > interpret it as saying that if I see them, I agree to their terms for > payment (as I have not opted out of Medicare). Seto has the > resources re: how it works if you have opted out. If you have a > signed contract with Humana, that seems like a different beast. I am > treated as non-participating for the rare non-Medicare Humana patient > I see. > > Re: the original question about sending records is an easy fix- charge > them or tell them to come get them. I find it very easy to fax my > records from my EMR but will starting requesting payment prior to > faxing from now on. > > Carla Gibson FNP > > ------------------------------------------------------------------------ > *From:* Ellen son > *To:* > *Sent:* Sunday, September 6, 2009 9:11:09 AM > *Subject:* Re: Scoop on Humana > > > > Nothing like this is in the contract I recently received. I doubt > whether anything stated as below could be legal. Why would insurance or > any of us bother with any contracts if this were true? If you are not on > an insurance panel, then your care should be out of network for that > pt. I have a few pts who see me out of network and they have to pay > more out of pocket. I have nothing pro/con to say about Humana > as I have no experience with them but what you have written is not as a > " direct quote " and you also say it was from a couple of years ago. I > think we ought to be careful what we put out to everyone > as fact. > > Ellen > > Carla Gibson wrote: > > > > I did not contract with Humana- I simply saw Humana Gold Choice > > patients... If you see the patient, then you are agreeing to the terms > > they offer. This is from a Humana Brochure and similar to what I > > remember reading from one of their letters a couple of years ago: > > > > What is a participating provider? > > A participating provider is a physician or other health > > care provider who knows of a member's enrollment in a > > Humana MA PFFS plan and has been given a reasonable > > opportunity to obtain the terms and conditions for > > payment for services provided to a Humana MA PFFS > > plan enrollee. Physicians and other health care providers > > must be licensed and must be eligible to provide care > > to Medicare-eligible patients, with no sanctions against > > their licensure. If a physician or health care provider > > renders care to a Humana MA PFFS plan member, > > the physician or health care provider is considered > > participating for that member. For a copy of our full > > terms and conditions, please call Provider > > Relations at 1-. > > Does the physician have a responsibility > > to somehow notify the plan that he or she > > is participating? > > No. There are no contracts to sign, and there is no > > paperwork required to participate. The physician or > > other health care provider simply needs to see the > > member's ID card to identify the individual as a Humana > > MA PFFS plan member. The physician or other health > > care provider should review the terms and conditions of > > payment. If the provider renders care to the member, > > that provider is participating. A physician or other > > health care provider may choose to provide care to > > Humana MA PFFS plan enrollees on a patient-by-patient > > basis and may stop treating enrollees at any time. > > > > Carla Gibson FNP > > Missoula, MT > > > > ------------ --------- --------- --------- --------- --------- - > > *From:* Robbins Health Alliance <robbinshealth@ yahoo.com > <mailto:robbinshealth%40yahoo.com>> > > *To:* Practiceimprovement 1yahoogroups (DOT) com > <mailto:%40yahoogroups.com> > > *Sent:* Thursday, September 3, 2009 9:35:41 PM > > *Subject:* Re: [Practiceimprovemen t1] Scoop on Humana > > > > > > > > that's exactly why I refuse to accept Humana > > > > The Robbins Health Alliance > > 1324 Rockbridge Road, SW > > Stone Mountain, GA 30087 > > PH: > > Fax: > > www.robbinshealth. com <http://www.robbinsh ealth.com > <http://www.robbinshealth.com>> > > Your first choice for Internal and Holistic Medicine. > > > > > > > > > > > > > > > Humana has just moved to town and has sent me a contract. I > > > cherry-pick my insurance companies and generally only > > contract with > > > those that treat physicians well, meaning reasonable > > reimbursement > > > along with minimal hassles. Does anyone know how Humana > > is with > > > respect to promptness of payment, refusing to pay for > > technicalities, > > > requiring chart notes and documentation, requiring lots > > of pre-auths > > > and paperwork for drugs/studies, etc? > > > > > > Thanks! > > > Jen Wallace > > > > > > > > > > > > ------------ --------- --------- --------- --------- --------- - > > > > > > > > > > Attachment: vcard [not shown] Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 7, 2009 Report Share Posted September 7, 2009  1) even with the "change of insurance," you should be cautious about abandonment issues. 2) Agree with health care -- people may very well get for what they pay for, meaning NOT getting what they THINK they've paid for.......... Matt in Western PA * Re: [Practiceimprovemen t1] Scoop on Humana>> >>> >>> >>> > that's exactly why I refuse to accept Humana>> >>> > The Robbins Health Alliance>> > 1324 Rockbridge Road, SW>> > Stone Mountain, GA 30087>> > PH: >> > Fax: >> > www.robbinshealth. com <http://www.robbinshealth.com >> <http://www.robbinsh ealth.com>>>> > Your first choice for Internal and Holistic Medicine.>> >>> >>> > >> > >>> > >>> > > Humana has just moved to town and has sent me a contract. I>> > > cherry-pick my insurance companies and generally only>> > contract with>> > > those that treat physicians well, meaning reasonable>> > reimbursement>> > > along with minimal hassles. Does anyone know how Humana>> > is with>> > > respect to promptness of payment, refusing to pay for>> > technicalities,>> > > requiring chart notes and documentation, requiring lots>> > of pre-auths>> > > and paperwork for drugs/studies, etc?>> > >>> > > Thanks!>> > > Jen Wallace>> > >>> > >>> >>> >>> > ------------ --------- --------- --------- --------- --------- ->> >>> >>> >>> >>>>> <nellegreen. vcf>>> Quote Link to comment Share on other sites More sharing options...
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