Re: OrthoNet

[Guest guest]

This is an emerging topic at RehabEdge. In a word, orthonet " stinks. "

http://physicaltherapy.rehabedge.com/tm.aspx?m=68961

M. Ball, PT, DPT, PhD, MBASpinal Manipulative Therapist

Northeast Rehabilitation, Staff Physical Therapist

Phuzion Institute for Physiotherapy Education, President and Chief Education

Officer

http://phuzioninstitute.com

To: PTManager

From: bzyheidi1@...

Date: Wed, 6 Oct 2010 12:51:20 -0400

Subject: OrthoNet

Just curious how everyone feels about the Orthonet/Humana situation. Is anyone

else having issues with the pre-certs from Ortho-Net? We are seeing them really

limit a patients visits when the medical necessity is still there according to

the doctor and PT. It is very frustrating to us and patients when we call for

benefits and told they have say, 60 visits a year and Orthonet will only let

them use 8 of them. It seems to me when employers purchase these benefit plans,

this is part of the package. (Although I know the medical necessity needs to be

proven). I know its another way for insurance companies to save $ but wondered

if other clinics and getting more and more frustrated with this process with

Orthonet. Thanks!

Heidi Harmon

Billing Manager

[Guest guest]

I would bet that everyone feels the same way you do. They are very

frustrating to deal with and their required copays keep increasing as well.

Ask for a reference # from Humana when you make the verification phone call.

They will provide that and somehow, when they have to give that number out,

they are much more detailed on orthonet requirements. The Humana reference

# is related back to the phone call, but is not the same as the

authorization number for visits obtained via Orthonet. We also have to

specifically ask Humana if the eval and/or follow up visits require orthonet

precert as the eval may not, but follow up appointments do. Orthonet

requires a particular fax cover sheet and we have had denials if that is not

sent in on the day of the evaluation. You also have to send a copy of the

eval and script. We generally get 1/2 the number of visits that we

request from orthonet whether we have requested 4 or 12. Read their

precertification letters carefully. They will often say that visits are

denied, but they approve part of the request. I would also suggest you

monitor the credentialing status-we have had them not recognize providers

and deny payment even when they are listed on the authorization.

Good luck,

Krista

Krista Sheppard, PT

Director of Therapy Services

Orthopedic & Sports Medicine Center

2200 Fort Rd. Ste 250

Normal, IL 61761

Phone x 243

Fax

kristas@...

_____

From: PTManager [mailto:PTManager ] On Behalf

Of @

Sent: Wednesday, October 06, 2010 11:51 AM

To: PTManager

Subject: OrthoNet

Just curious how everyone feels about the Orthonet/Humana situation. Is

anyone else having issues with the pre-certs from Ortho-Net? We are seeing

them really limit a patients visits when the medical necessity is still

there according to the doctor and PT. It is very frustrating to us and

patients when we call for benefits and told they have say, 60 visits a year

and Orthonet will only let them use 8 of them. It seems to me when employers

purchase these benefit plans, this is part of the package. (Although I know

the medical necessity needs to be proven). I know its another way for

insurance companies to save $ but wondered if other clinics and getting more

and more frustrated with this process with Orthonet. Thanks!

Heidi Harmon

Billing Manager

[Guest guest]

We are having the same issues with Orthonet. If we ask for 12 visits, they

might give us 5. So we are having to do re-evals every 5 visits or so on

most of the Orthonet patients. It is very frustrating to say the least!

Especially on complicated patients with a rotator cuff repair or something

like that where they will need to come for a long time. We are still

accepting Humana patients at this time, but my boss is so upset with them

that we changed our employees' insurance carrier to BCBS. We have been

telling the patients to call Humana & file complaints against Orthonet and

to also let their employers know about it. That way when it comes time to

renew their policies, people might feel differently about Humana.

>

>

>

> Just curious how everyone feels about the Orthonet/Humana situation. Is

> anyone else having issues with the pre-certs from Ortho-Net? We are seeing

> them really limit a patients visits when the medical necessity is still

> there according to the doctor and PT. It is very frustrating to us and

> patients when we call for benefits and told they have say, 60 visits a year

> and Orthonet will only let them use 8 of them. It seems to me when employers

> purchase these benefit plans, this is part of the package. (Although I know

> the medical necessity needs to be proven). I know its another way for

> insurance companies to save $ but wondered if other clinics and getting more

> and more frustrated with this process with Orthonet. Thanks!

>

> Heidi Harmon

> Billing Manager

>

>

[Guest guest]

We have had difficulties with Orthonet as well. They have a contract with BCBS

of New Hampshire and communication between both companies is poor which has

resulted in Orthonet denying requests because we did not respond to their

requests for supporting documentation in a timely manner. Both companies insist

info should go to them first, paperwork gets lost, faxes dont arrive. Very

frustrating and time consuming.

Diane Maxson, MHA, MS, OTR/L

Therapeutic Learning Center

>

> >

> >

> >

> > Just curious how everyone feels about the Orthonet/Humana situation. Is

> > anyone else having issues with the pre-certs from Ortho-Net? We are seeing

> > them really limit a patients visits when the medical necessity is still

> > there according to the doctor and PT. It is very frustrating to us and

> > patients when we call for benefits and told they have say, 60 visits a year

> > and Orthonet will only let them use 8 of them. It seems to me when employers

> > purchase these benefit plans, this is part of the package. (Although I know

> > the medical necessity needs to be proven). I know its another way for

> > insurance companies to save $ but wondered if other clinics and getting more

> > and more frustrated with this process with Orthonet. Thanks!

> >

> > Heidi Harmon

> > Billing Manager

> >

> >

[Guest guest]

We, too, are struggling with Orthonet, but with Cigna as the carrier. We are

also telling patients to complain to Cigna. One of the other issues we have

dealt with is a patient showing up as a walk in from clinic late on Friday. We

often are unable to get Orthonet on the phone, and they refuse on Monday morning

to back-date an approval. We have been going directly to Cigna to intervene

with at least some success.

Mickey Bonk, PT, MBA

Administrator, Rehab Services

Children's Memorial Hospital

[Guest guest]

We were an in-network provider with Orthonet and United Health Care.  Both

organizations had burdensome administrative requirements, as you describe. 

That

is why we are not an in-network provider with either entity today, and I am

proud to say that our business has not been adversly affected by this decision.

Sumesh 

________________________________

To: PTManager

Sent: Thu, October 7, 2010 9:44:40 AM

Subject: Re: OrthoNet

 

We are having the same issues with Orthonet. If we ask for 12 visits, they

might give us 5. So we are having to do re-evals every 5 visits or so on

most of the Orthonet patients. It is very frustrating to say the least!

Especially on complicated patients with a rotator cuff repair or something

like that where they will need to come for a long time. We are still

accepting Humana patients at this time, but my boss is so upset with them

that we changed our employees' insurance carrier to BCBS. We have been

telling the patients to call Humana & file complaints against Orthonet and

to also let their employers know about it. That way when it comes time to

renew their policies, people might feel differently about Humana.

>

>

>

> Just curious how everyone feels about the Orthonet/Humana situation. Is

> anyone else having issues with the pre-certs from Ortho-Net? We are seeing

> them really limit a patients visits when the medical necessity is still

> there according to the doctor and PT. It is very frustrating to us and

> patients when we call for benefits and told they have say, 60 visits a year

> and Orthonet will only let them use 8 of them. It seems to me when employers

> purchase these benefit plans, this is part of the package. (Although I know

> the medical necessity needs to be proven). I know its another way for

> insurance companies to save $ but wondered if other clinics and getting more

> and more frustrated with this process with Orthonet. Thanks!

>

> Heidi Harmon

> Billing Manager

>

>

[Guest guest]

We are finding the problem with Humana policies replacing Medicare as they use

OrthoNet.

We have found success dealing with them by following the following steps. The

key was following this scenario.

1) We received orders for right rotator cuff PT s/p surgery. Order was for 3 x

week x 4 weeks for PROM only and then pt. to follow up with surgeon

2) We received approval for 5 visits.

3) After the patient used the first 5 visits we did the re-eval. We explained

in the re-eval why they should be given the additional 7 visits.

4) OrthoNet approved 3 additional visits.

5) It was at this point that the patient appealed directly to Medicare.

Medicare sent the appeal to Maximus Federal Services (they are hired by Medicare

to review files and decide if the health plan made the right decision) and they

ordered OrthoNet to give the additional 7 visits.

6) Pt. utilized the twelve visits and visited physician.

7) MD ordered twelve additional visits for AROM and then move to strengthening

when full AROM achieved.

8) OrthoNet approved 4 visits.

9) Patient appealed to Medicare again (this time before the 4 visits were used)

and Maximus sent an order to OrthoNet to approve the twelve additional visits.

So, the moral of the story is (with Humana as a Medicare replacement

policy).....Don't keep fooling around with OrthoNet but appeal directly to

Medicare on these replacement policies. And, very important, this has worked

with two other patients.

Separate point: We are starting to see OrthoNet being used by a private insurer

and that's a whole different problem as their is nobody to appeal to and private

insurer won't back you up.

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc

Bay St. Louis and Diamondhead, Mississippi

Re: OrthoNet

We are having the same issues with Orthonet. If we ask for 12 visits, they

might give us 5. So we are having to do re-evals every 5 visits or so on

most of the Orthonet patients. It is very frustrating to say the least!

Especially on complicated patients with a rotator cuff repair or something

like that where they will need to come for a long time. We are still

accepting Humana patients at this time, but my boss is so upset with them

that we changed our employees' insurance carrier to BCBS. We have been

telling the patients to call Humana & file complaints against Orthonet and

to also let their employers know about it. That way when it comes time to

renew their policies, people might feel differently about Humana.

>

>

>

> Just curious how everyone feels about the Orthonet/Humana situation. Is

> anyone else having issues with the pre-certs from Ortho-Net? We are seeing

> them really limit a patients visits when the medical necessity is still

> there according to the doctor and PT. It is very frustrating to us and

> patients when we call for benefits and told they have say, 60 visits a year

> and Orthonet will only let them use 8 of them. It seems to me when employers

> purchase these benefit plans, this is part of the package. (Although I know

> the medical necessity needs to be proven). I know its another way for

> insurance companies to save $ but wondered if other clinics and getting more

> and more frustrated with this process with Orthonet. Thanks!

>

> Heidi Harmon

> Billing Manager

>

>