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Humana Lawsuit
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Dear OSCA Members:

As OSCA pursues its lawsuit against Humana for the alleged overpayment and recoupment activities involving non-contracted providers, we want to remind you of a couple action items.

1. Please continue appealing any overpayment notices you receive. Remember there are three levels of appeal, and it is important that you complete each level as you receive determination letters on your appeals.

2. Please continue sending OSCA legal counsel information regarding the alleged overpayment notices your practice receives, as well as information regarding any amounts recouped and any appeal information. In particular, we are interested in seeing the following:

a. Copies of Overpayment Notices
b. Dates and amounts recouped for alleged overpayments from other patient claims
c. Copies of all appeals and determination letters regarding those appeals

With regards to appeals, we recommend that you timely appeal any denials or overpayment notices from Humana. The policies for Humana do not clearly specify which appeals process we are under for the current scenario. As such, for Appeal Level 1, we recommend that providers appeal within the 30 day timeframe set forth in the On-Site and Desk Audit Appeal Policy, as that is the shortest timeframe. That being said, after that, there are 2 routes: (1) the determination letter issued by Humana will set a timeframe for appeal, or (2) default to the appeal process set forth in the Provider Payment Integrity Post-Pay Clinical Audit Appeal Process.

For an Appeal Level 2, providers should file their appeal within 60 days of the date of Humana’s Level 1 outcome letter. The Level 2 appeal will be sent to a third-party vendor. The overpayments are supposed to be placed on hold so that monies are not recouped or offset from future payment until the appeal is resolved. Finally, there is a Level 3 appeal, which must be filed within 60 days of the date of the Level 2 outcome letter. Humana’s internal clinical physician review team or internal coding team will conduct the review.

Appeals should be sent by fax to 1-888-815-8912 or via mail to:

Humana Provider Payment Integrity Clinical Audit Appeals
P.O. Box 14279
Lexington, KY 40512-4279.

All appeals should be sent in a manner that the provider can confirm Humana received the appeal via a tracking method.

Humana’s policies state that “reasonable extensions will be granted for all levels of appeal.” As such, providers should appeal regardless of whether they meet applicable deadlines.


 


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phone: (800) 837-6721 | (614) 229-5290
fax: (614) 229-5296 | email: osca@oscachiro.org


 

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