Humana Implementing 8 Payment Changes for Outpatient Therapy

February 26, 2018
Rick Gawenda

Humana has announced 8 payment changes effective March 1, 2018 that will impact providers of outpatient physical, occupational and speech therapy services. While Humana states the effective date is March 1, 2018, it appears that the changes may have already been implemented with dates of service on and after January 1, 2018. Effective with dates of service on and after March 1, 2018, Humana will no longer pay for the following CPT codes:

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  1. I have seen that these changes did go into affect prior to 3/1/18 as we have been getting denials for these codes. Since the beginning of the new year.

    1. If you have any questions regarding what products the policies apply to, I would recommend you contact Humana.

  2. Rick,
    As I’m not certain what is and what is not considered a “commercial fully insured product”, would this policy change apply to beneficiaries covered under Humana’s Medicare ‘Advantage’ plan?

    1. If you have any questions regarding what products the policies apply to, I would recommend you contact Humana.

  3. Humana usually tells us that they follow Medicare Guidelines- if that is the case shouldn’t 97113 be covered in those instances? That is how we have gotten them to pay the denials this year so far- but I assume that will change March 1.

    1. If you have any questions regarding what products the policies apply to, I would recommend you contact Humana. Humana Medicare Advantage plans may or may not be considered a commercial fully insured product.

    2. Humana does not have to pay the same CPT codes that the traditional Medicare program does. Humana can decide which CPT codes they will pay for and by what discipline.

  4. I just checked and Humana Gold Plus (Medicare Replacement) has begun denying aquatic sessions as of 2/1/8. I can’t imagine how this is legal for them to do before they announce it.

  5. We have been unable to talk to anyone who has meaningful ability to answer questions. They have been recouping payments going back 6-8 month, questioning our documentation which has always been acceptable until June of 2016. We are beyond frustrated with them! Do you have any other suggestions for how to remedy this problem? Is this something your firm could help us with?

      1. Rick are these “recommendations” something that we Gold Members can have access to? As we are all feeling these frustrations. It will likely take a united effort from all of us to remedy…

        1. Due to liability reasons and contracts I have in place with Clients, my recommendations to a client is for the sole use of the client.

  6. DROP them!!! Constant BS from them just as Jane mentioned for 2+ years until we were fed up with them. Dropping them was an eternal 8 month nightmare as well. Monthly follow up calls asking for an effective termination date only to be told “in processing/review.” Then when push came to shove, we started calling weekly to confirm but still being told “processing” until one day a rep told us “I see your contract was finalized TWO MONTHS AGO!” And of course we had to start a whole new dialogue to get our claims paid in network as we were NEVER provided the termination date in writing. They are garbage.

  7. Any advice on what to bill in place of 97113? Therapeutic Activities 97530? Thanks for your updates!

    1. If Humana is not paying for aquatic therapy, then you would not want to do aquatic therapy. You can’t do aquatic therapy and bill it under a different CPT code unless the insurance carrier allows it. If allowed by your contract, you would want to bill the patient for noncovered services they receive from you.

  8. I spoke with customer service at Humana this afternoon regarding a Medicare replacement plan and was told that 97113 (Aquatics) is a non-covered service. Humana also told me that since they follow Medicare guidelines, and Medicare pays for this service, they should pay for it as well. In the past, I have been able to submit an appeal stating this procedure is a covered service under Medicare guidelines when a denial was received.

    1. Humana is not required to pay for aquatic therapy. Humana Medicare Advantage plans must provide the same services as traditional Medicare (ie. PT, OT and SLP), but they can decide what CPT codes they will and will not pay for.

  9. Rick – can you give any links to where we may find the coverage guidelines that Humana is using? This week we had an outpatient ST claim reject 92523 ST eval language exp/rec as a non-covered code by Humana. Trying to figure why. A dx code edit? A limitation on evaluations per time frame? I can not find answers anywhere or get anyone at Humana to state why this claim rejects.