Interesting clawback from Humana

[drrosenrosen]

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Got a "refund request" from our good friends at Humana today. Clawing back two 99204s and one 99214 because "diagnosis code(s) are inappropriate". The only code all three charts have in common is G894 chronic pain syndrome. None of them use it as a primary or even secondary diagnosis, but as a 3rd or 5th diagnosis. Just a heads up don't use that code at all for Humana pts.

 

[Agast]

I only use G89.4 when I’m planning on doing a stimulator and it helps me remember who I spoke to about it when it’s in their chart.

 

[drrosenrosen]

Yeah I have removed it from all of my templates so that I'll only use it for SCS cases in the future as well

 

[buddababa]

Got a "refund request" from our good friends at Humana today. Clawing back two 99204s and one 99214 because "diagnosis code(s) are inappropriate". The only code all three charts have in common is G894 chronic pain syndrome. None of them use it as a primary or even secondary diagnosis, but as a 3rd or 5th diagnosis. Just a heads up don't use that code at all for Humana pts.

well i hope you're not going to pay them back?

 

[drrosenrosen]

well i hope you're not going to pay them back?

We're appealing. Because it's only 3 patients, it's only $300, but it's the principle more than the money

 

[Doctodd]

Did they already claw it back or are they trying to clawback? There’s no way to have some fun with them? Without wasting your time?

 

[painfree23]

I don’t get it. Why can’t a patient have a chronic pain diagnosis and you bill for it?

 

[Asclepius186]

Same. What’s the problem with g89.4? Never heard of that causing an issue

 

[Agast]

http://www.decisionhealth.com/getstartedhhcc/pdf/HHCCTipsAndTricksPainHandouts18Dec17.pdf

I wonder if it gets flagged on new patient encounters due to chronicity question. But Humana has been having major financial problems and they are probably trying to claw back whatever they can.

 

[drrosenrosen]

Did they already claw it back or are they trying to clawback? There’s no way to have some fun with them? Without wasting your time?

They've "requested" it back. But you know they're playbook - if I don't send them a check, they'll just garnish it from future payments. I'm sure we'll get it overturned on appeal but it's infuriating that we have to waste time and resources on bull**** like this.

 

[geauxg8rs]

They've "requested" it back. But you know they're playbook - if I don't send them a check, they'll just garnish it from future payments. I'm sure we'll get it overturned on appeal but it's infuriating that we have to waste time and resources on bull**** like this.

You could Contact your state insurance regulators and AG

 

[PainandGain]

I’ve heard some payers are requesting clawbacks on nonspecific codes especially associated with level 4/5 visits. Resubmit with specific codes.

 

[PinchandBurn]

They've "requested" it back. But you know they're playbook - if I don't send them a check, they'll just garnish it from future payments. I'm sure we'll get it overturned on appeal but it's infuriating that we have to waste time and resources on bull**** like this.

Hey I have seen this with uhc.


Who is helping you appeal this?ur billers?

This is a PIA and uses resources..

 

[drrosenrosen]

I’ve heard some payers are requesting clawbacks on nonspecific codes especially associated with level 4/5 visits. Resubmit with specific codes.

Yes there are at least 3 specific codes for each one of these. It's just that g894 is also on the note, which is apparently the reason for the denial.

 

[Pain Applicant1]

Got a "refund request" from our good friends at Humana today. Clawing back two 99204s and one 99214 because "diagnosis code(s) are inappropriate". The only code all three charts have in common is G894 chronic pain syndrome. None of them use it as a primary or even secondary diagnosis, but as a 3rd or 5th diagnosis. Just a heads up don't use that code at all for Humana pts.

No, don't give it back. Resubmit the claim using a more detailed code. Addend the note to add the new code and resubmit. I assure you you will get paid for these.

I would call them on this one if I had to. You can capture these claims, trust me.