Humana Ordered To Pay In Provider Dispute

Nov 27, 2019

Humana has been ordered to pay $4,673 to Holy Cross Emergency Room Physicians under a final order issued by the state Agency for Health Care Administration. 

In the Nov. 19 final order, AHCA also demanded that Humana pay $875 to MAXIMUS, which has a contract with the state to review disputed claims between health-care providers and health maintenance organizations, exclusive provider organizations, prepaid health plans and health insurance companies.

According to the final order, the dispute involved nine claims. MAXIMUS ruled in favor of Holy Cross Emergency Room Physicians on all nine claims.

The final order can be appealed. According to a 2018 annual report, 70 cases were filed with MAXIMUS for review in 2018. But just six of them met the eligibility requirements for review. For example, MAXIMUS doesn’t review cases that don’t meet certain financial thresholds or Medicare or Medicaid cases.

Ultimately, the majority of the six cases that were eligible for review were either settled or withdrawn. There was only one disputed case that MAXIMUS reviewed last year. Ultimately MAXIMUS ruled in favor of the provider.