Humana Choice Problem in Texas?

[GreenSky]

Although I'm in So Cal, I received a call from a prospect in Texas who told me that Baylor University Medical Center as well as a huge number of physicians will no longer accept the Humana texas PFFS plan. They are fine with the PPO, just not PFFS.

Anyone have an idea of what's going on? I would have thought that the reimbursement rate is higher on the PFFS than PPO.

Is Humana having claims issues?

Rick

 

[Cenla Agent]

PFFS is supposed to pay the same as Medicare. The only issue I can think of off the top of my head is about what is considered "medically necessary". IOW there may be closer scrutiny of the charges than what they are used to with Medicare.

My understanding is that if a provider is contracted for the Humana HMO or PPO then they have to take all of the Humana MA plans in the area, including PFFS.

 

[midwestbroker]

Humana is looking to focus more on the HMO / PPO market. They have the PFFS plans, but I am willing to bet that they reimbursement rates are not as much as the PPO.

The HMO / PPO market is more profitable for them.

They also have no intention to offer a stand alone PFFS. Humana uses the part D side to make claims to Medicare for more reimbursement on an individual member basis. If they offer a stand alone PFFS, they cannot do that.

 

[Cenla Agent]

I am certainly not an expert on the provider side of managed care, but I think the contracted providers in a HMO (and maybe PPO) receive a certain amount of money from the insurance company every month whether they see the patient or not.

 

[Cenla Agent]

Humana is looking to focus more on the HMO / PPO market. They have the PFFS plans, but I am willing to bet that they reimbursement rates are not as much as the PPO.

The HMO / PPO market is more profitable for them.

They also have no intention to offer a stand alone PFFS. Humana uses the part D side to make claims to Medicare for more reimbursement on an individual member basis. If they offer a stand alone PFFS, they cannot do that.

I continue to hear that they are looking to expand the HMO to new areas here. Don't know about the PPO since it came in at a pretty high premium (in LA anyway) and went up in 2007, although the out of network benefits were better in some cases.

 

[Cenla Agent]

Humana is looking to focus more on the HMO / PPO market. They have the PFFS plans, but I am willing to bet that they reimbursement rates are not as much as the PPO.

The HMO / PPO market is more profitable for them.

They also have no intention to offer a stand alone PFFS. Humana uses the part D side to make claims to Medicare for more reimbursement on an individual member basis. If they offer a stand alone PFFS, they cannot do that.

If the PFFS is not that profitable for Humana, then how profitable can it be for other insurers who offer stand alone PFFS plans with much lower premiums (0 in some areas) and often richer benefits? But maybe I read too much into it since you said HMO and PPO is more profitable, not that Gold Choice was unprofitable.

 

[midwestbroker]

Humana is more money from the PPO and HMO's then the PFFS plans. Not that the PFFS plan is not profitable, just not as profitable.