I know the posts have been intense lately…that’s b/c things are intense. I am hoping that this blog post will be the stick of dynamite needed to blow us out of our mine shaft, which is the term we’ve coined for our really tough season of life. This blog isn’t just about our victories, it’s about our struggles.
As a Realtor, my customers have called me a pit bull. If that’s how I am in business…how do you think I’ll be when it comes to my daughter? The term “Pit Bull” seems pretty inadequate.
Below is an email I just sent to our personal nurse at Humana, she is awesome by the way. A series of events have unfolded leading everyone working on Reagan’s care to believe her file has been tampered with. As of last week, Humana was saying that Reagan only had 72 additional therapies authorized, this was confirmed by our Humana nurse, by the rehab place, and by Nemours. However, now, they are saying that even those are denied. Meaning, that all the therapies we’ve had for Reagan in the months of June and July (totaling 81) will be denied. Read the below email I sent and then please share, post, send to a news outlet, I don’t care. Reagan will get the attention she needs and this story will be told.
tell my story.
Subject: Tampering with Reagan Wurzel’s medical records
Holly,
Rob and I believe Humana has been tampering with our daughter’s records. I am requesting your IT/IS department to pull who has made alterations to our account, and what was made and on what day. An internal investigation needs to be opened into this issue. Here’s the chain of events:
May 22 Notes from Dr. Ried’s office
Dr Ried spoke with a reviewer who authorized 72 visits per specialty, PT, OT, ST, Feeding. until Sept 20,2014.
The auth # is 064426015 and the phone number is 800-833-6917. I am requesting the call to be pulled, again.
May 28 – Florida Hospital Rehabilitation confirmation call
Elvira with Florida Hospital Rehabilitation called Humana and confirmed with “Jenny M” that the authorization code was indeed for 72 therapies per discipline. She called in the morning time, please pull the call. If the call on May 22nd didn’t happen or can’t be found, like Humana wants to continually say, then Elvira couldn’t have used the auth code to confirm the therapies with Jenny M.
July 22 – Florida Hospital Rehabilitation call
Elvira spoke with “Ziolata G” to check on Reagan’s account. Ziolata could only confirm 72 therapies for PT under the code 97110. The reference number for this call is 6302813623617. Please pull the call.
July 25 – letter from Humana (date on the letter is July 25th)
We receive a contractual denial letter from Humana stating that we are being denied therapies and that our policy only covers 30. My husband spoke with someone at Humana on July 29th who said this is the second time the letter has been sent, however we did not receive a previous letter and we have been looking for letters from Humana, and we scan every single document from Humana into our computer. The person at Humana that my husband spoke with said they could only see something from May 20. Even if that were true, all authorizations for therapies which were confirmed with two parties (Nemours and Dr. Ried’s office and Elvira with Florida Hospital Rehabilitation) came after that date.
Further points to consider which suggest record tampering:
- A Sept. 20th date. Why would that date be provided by Humana? If we have a contractual agreement for 30 therapies, why would they provide a date of Sept. 20th to use them by? The reason: B/c it was not for our contractual agreement, it was for the 72/discipline.
- Two providers on two separate dates confirmed with Humana the 72/discipline
- Two months later, Elvira decides to inquire about Reagan’s account, and she confirms with Ziolata 72 for PT under the PT code
- Now, there is no record of 72 for just PT, only 30 per our contract.
Today, my husband will be contacting the Florida Department of Insurance to file a formal complaint and to request an investigation be opened. Please put me in touch with whatever department handles this sort of thing, and please put me in touch with someone who is the head of the department. I am also requesting for a second time in this email that the IT/IS department look at Reagan’s account to see who changed what, and on what dates and times, b/c there is more than enough evidence to suggest a tampering with our daughter’s records.
While Humana may be audited (and uses this as an excuse to cover up their previous authorization) an audit of Humana is not of concern to us. What is of concern to us is what Humana said would be provided and confirmed by two separate providers. That is our concern. This series of events will not be placed on our shoulders to bear; if Humana made a mistake, if they made multiple mistakes, then Humana needs to bear that burden. Believe me when I say, this will get the attention it deserves one way or another.
Other facts to consider about our previous authorization and confirmation of additional therapies:
- Page 22 of our policy defines what is considered outpatient therapies which is limited to 30 total visits per calendar year
- Page 25-26 defines what is considered rehabilitation services, this does not limit us to 30 total visits per calendar year and does include PT, OT, Speech outlined
- Reagan did not break her leg and require 30 therapies to help her walk again. What happened to Reagan altered her entire life and 30 therapies will not fully rehabilitate her, it won’t even come close. As I mentioned before, when Reagan left the hospital, she was not able to hold her head up on her own. Three months later, she was pulling herself to stand in her crib. The therapies are working, and we are not only requesting Humana to re-instate the 72/discipline, but to do so through the end of the year, since we have had to halt any further therapies until this is sorted out.
Feel free to forward this email along to anyone you see fit and know that I will be doing the same. Thank you for your hard work so far, and I look forward to working with you to resolve this.
Sincerely,
AM
July 30th, 2014 at 4:09 pm
This is completely unacceptable and deplorable.
July 30th, 2014 at 7:36 pm
Rachel, you know that I could not agree more.
July 30th, 2014 at 4:51 pm
Anne-Marie & Rob,
I have sent a copy of this blog onto a friend of mine who works at Fox 35. Fingers crossed she’ll pick up the story 🙂 I’ll keep you and Jen posted. As always, your family is in my continued prayers.
July 30th, 2014 at 7:26 pm
Am, I am with you all every day in prayers . Love, Granny C
July 30th, 2014 at 7:35 pm
Thanks Granny C!
July 30th, 2014 at 7:35 pm
Thank you Melissa!
July 30th, 2014 at 7:14 pm
Did you follow the grievance and appeal process with Humana?
July 30th, 2014 at 7:35 pm
Yes. more than once.
July 30th, 2014 at 7:53 pm
You go mama. There is not one much mightier than a mother fighting for her child. Great record keeping too.
July 30th, 2014 at 8:17 pm
AM…just wanted you to know that you and your precious family are continuously in my thoughts & prayers! If you ever need anything, please don’t hesitate to ask! <3
July 31st, 2014 at 1:27 am
Anne-Marie,
Has the hospital contacted their humana provider rep in regards to the denial of these claims?
July 31st, 2014 at 1:34 am
Yes. We have all received the same confirmations and denials through the process.
July 31st, 2014 at 6:01 pm
How come the state of Florida isn’t covering her therapies? Are you not eligible for the early steps program?
July 31st, 2014 at 6:07 pm
Our previous meeting with Early steps did not go great, they offered us to pick ONE discipline, once a week, which is not enough.
August 1st, 2014 at 12:50 am
You may also want to send emails with links to this post the the Humana PR and communications team. They may want to get in front of the story by escalating your inquiry.
August 1st, 2014 at 12:54 am
Humana has been in contact with me and I believe our case is at the highest level. Believe me, they are aware of the blog. Thank you!!
August 1st, 2014 at 5:24 pm
Hi Anne-Marie!
That is absolutely ridiculous!! I’ve had many issues with health insurance companies before, but nothing like this. Have you contacted a lawyer about this? I work with LegalShield and the Orlando Lawfirm we work with is DeBeubien, Knight, Simmons, Manzaris and Neal and they handle health insurance disputes and other cases like this a lot. The legal plan is extremely affordable ($17/month) and helping your case would count as one of the covered benefits. I’d love to help in any way I can, feel free to call me at 407-310-3447. Take care and God bless!
August 2nd, 2014 at 2:09 am
Anne- Marie and Rob: My nickname for Humana is “HumanLESS”. A dear friend of mine’s daughter in law is a corporate sales rep for Humana based in Atlanta. She works 40 hours a week and makes a six figure salary. The amount of money Humana spends on sending her and other reps to various 5 star hotels around the country for rewards and conferences is outrageous. The most recent one was at the Boca Raton Hotel and Club in Boca Raton. They also flew her and a client first class to the Superbowl, all expenses paid, with accommodations at high end hotel and skybox seats. Humana spent over $500,000 on a hospitality tent at a golf tournament in Atlanta. Imagine how many sessions that would pay for Reagan. It makes me sick when I think about what you are going through and how you are having to fight them when your energies should be spent on Reagan.