[Regina]

Is anyone else finding the people who are employed by the Medicare HMOs to be woefully uninformed? I just had to explain to an Aetna rep that hospital beds are a rental, and yesterday I questioned an Aetna supervisor regarding the denial of a soft cervical collar as a non-covered item. I am still waiting(three weeks) for a supervisor at Bravo to get back to me concerning months worth of claims for diabetic supplies that they continue to deny for modifiers, yet can not tell me what modifiers they want. They say Medicare modifiers, but when we bill with KX they still deny. The supervisor could not help me with any policy questions, as he is just, as he said, "customer service". Don't you think supervisors in provider services should be able to answer policy questions!? He was also stunned when I told him that Bravo provider service reps were, IMO, the worst trained in the industry. He answered that he thought they were all very professional and polite. I need answers as to why my claims deny, not just politeness!
Sorry, just needed to rant. I am tired of having my time wasted talking to idiots.

[HEATHER]

I know exactly what you mean. I can't stand to work with them. The only morsel I can offer to you is that usually when they talk about missing modifiers it is the RR, NU, UE, and KH, KI, KJ for rental items. We did a pwc thru Humana in March. Verified benefits, sent in our paperwork, got an auth #, submitted claim. Immediately rejected with "send in documentation." Called and told them we already did and got auth - "no problem we will reprocess - expedited." Then they paid the pwc as a rental when the claim clearly said NU. "No problem - we will expedite." That took them another 5 months. Then I received a recoupment letter for what they had paid. "This patient was on regular Medicare for this service date." That is the last time I accept assignment on a Humana claim.

[Regina]

We have tried NU, KX, & NU KX, but they don't like any of them. We also tried no modifier. Nothing has worked.
Why did Humana authorize the pwc if the patient was on regular Medicare at the time?!
We should not have to spend our time educating the people who work at these insurance companies.

[DeeDee]

Regarding the diabetic supplies. Is the patient on insulin? and does your diagnosis code match as well?

You would need a KS modifier if the patient is not on insulin.

I have found that the insurance's are checking to see if:
1. The Dx code indicates insulin dependent vs. non
2. Are they paying for insulin
3. The KS modifier

[Regina]

Believe me, Bravo isn't checking. Plus, tomorrow is officially one month since I e-mailed these issues to the manager at Bravo, and despite 2 additional e-mails and 3 phone calls, neither he nor anyone in his company has replied. I told him we will be turning away Bravo diabetic supply patients, but it doesn't seem to matter.

[Regina]

An update to this situation-
Bravo was paying our diabetic supply claims, and suddenly stopped paying for the test strips, again stating that we were not using the correct modifiers. Every week someone in our billing department would call, but no one could help us. Finally last week we demanded to speak to a supervisor, who told us that the modifiers they had in their system were NU and KL! But another "specialist" there agreed that our modifiers were correct, and said they will be taking care of this issue. They also said that sometime in the future they will be having an actual provider services department in addition to their woefully uninformed memeber services department. I'm not holding my breath waiting for either of these things to happen.