Wiki Humana Auths for stents

[leo061108]

I have a question about getting authorizations for stents for patients who have Humana (professional side). We have been told by Humana that they do not do retro-authorizations and that our physician would have to bring the patient in for a cath, close the patient, and then bring the patient back for a stent if they needed it, in order for us to be able to get a PA for the stent. Normally we would do the cath and stent in the same setting but Humana will not approve the stent when done this way.
And what about for the patients who our physician is unable to close and bring back due to the artery being highly stenosed.. he would have to stent right then?

Does anyone have this issue in there office? What is your practice for this?

 

[thomas7331]

This sounds to me like a line that someone in a claims department would give to try to get you off of the phone if you were calling to dispute a denied claim. I think whomever told you this must not have understood what they were talking about or else was not explaining it correctly. This is really complete nonsense and would be an absolutely unacceptable way for any provider to practice medicine. Providers must do what is right for the patient, and not less than that just because it is necessary to get payment - to do otherwise would be malpractice. Payers can set coverage guidelines but the cannot set administrative rules that dictate how a provider practices medicine or treats a patient.

There are many cases where providers must make a decision during the course of a procedure which would lead to a different code being billed than what was authorized. All payers understand this well and have ways to accommodate this type of situation. I would escalate this with someone at Humana, or talk to your network representative about it, or if all else fails, have your provider talk to a medical director at Humana. If a payer truly wants a provider to take a patient back through a second and unnecessary surgery just to meet their administrative requirements (which I really doubt is the case), then I would advise that provider not to do business with them.

 

[carelitz]

Are you referring to Humana HMO or PPO? There are different methods depending which. It also varies by state. Here in Florida, we have the same situation for Humana PPOs. What we do is make a note of "Humana PPO with cath and possible PCI." This alerts us that we need to HOLD THE BILLING until the procedure has been performed. Our auth department uses HealthHelp to obtain auths. After the cath and PCI are performed, our auth department goes onto the HealthHelp site and requests the auth for stent (92928 etc). At this point there are additional questions that asked about a cath (which was perfomed the same session) and sometimes records are requested (though not often). The auth is then obtained and we can then bill out the DOS. Basically you should be able to get the PCI auth if you have not yet billed out the procedure. This is how it works for us here, Your mileage may vary. Good luck!