Thursday, April 3, 2014


Promises, just promises

Ahh, Humana. Can you possibly make my life more frustrating?

It states, clearly in my Member Benefit Package, Page 34, that

    Mandatory Supplemental Benefit includes: - $115 annual eyewarecq benefit for eyeglasses or contact lenses and fittings from the network optical provider OR - One pair of eyeglasses at no cost annually, including ultraviolet protection coating.

Moving back in the same document I find one and a half pages of "Vision Providers." Among these providers is the optician I want to use.

The optician works with the ophthalmologist I initially wanted to use. My then-Primary Care Physician (PCP) told me I had a choice: go to the ophthalmologist with whom he had a "capitated" agreement or find a new PCP. I found a new PCP.

I've been told that "capitated agreements" return more money to the referring practitioner and the patient be damned. Capitated, as defined by Merriam-Webster online is found at the end of this entry.

My initial Humana PCP insisted that Humana demanded that I see an optometrist before I could see an ophthalmologist.

I checked on line and found a Humana-approved optometrist (with whom I was pleased). The OD told me to see an ophthalmologist to determine if a cataract was ready for surgery. If it was not, come back to order new lenses.

    It is my personal "Standard Operating Procedure" (SOP) not to have a prescription filled by the same practice that wrote the prescription; helps keep everyone honest. However, in this instance - since Humana was willing to pay $115 toward the package, I decided to return to the practice's optician.

    It turns out that the practice's intranet was "down" and the optician was unable to access my prescription. She refused to look at a printout I received when the eye exam was completed, and she refused - despite twice being told about a work-around - to do anything sans the intranet.

    No one bothered to try to find out WHY the intranet was down; no one called technical support; everyone was content to wait until the intranet finally came alive. I left before it did, if it did at all that day.

Having made an unnecessarily long trip (gas prices in Florida now average $3.64; about a dime above the national average) three times, I thought to use a Humana-listed provider closer to the manse.

I checked Humana's online provider's list. Sure enough, my preferred provider was listed, top of the list based on the search parameters I entered.

I went down to my nearby optician's office and talked to the Woman In Charge, hereafter The WIC.

I gave The WIC my Humana ID card and she tried - for several minutes - to find that I was covered. (Remember, the provider is on Humana's paper and online lists.)

Nothing, nada, effis. I'm the man who never was.

I went home and re-checked the Humana provider lists.

Then I called Humana Customer Service.

Pay attention, HIPAA

After playing 20 questions with Humana's voice response system I finally got a Customer Service Representative (CSR) to talk to me. First I have to answer - again - questions I already answered early in the call. (I shouldn't complain; it was Humana's dime.)

I explained the situation to the CSR and told him I found my preferred provider on Humana's lists.

Yes, they are on the lists, he agreed, only they are not on any list associated with my coverage.

    Sudden thought: I wonder if the CSR was looking at a list associated with my initial Humana PCP. I'll try again tomorrow.

NOW, THE HIPAA CONNECTION. While waiting to the CSR to research the issue I could clearly hear other CSRs' conversations with Humana clients, conversation that, per HIPAA, I should not hear. I mentioned this to the CSR and asked if Humana really did record client calls. He assured me it did and I repeated the information about hearing other clients' calls. (I followed up with an email to Humana that might be read by a low-level clerk before end of year when I will have a new Advantage provider.

In the end, I think I'm going to go to one of the several "two pair for $69" opticians; it will cost me closer to $115 (which Humana budgeted but …) but at least I'll be able to read house numbers again.

I would rather that Humana not promise something it has no intent to deliver. I'll chalk this up to "Lessons Learned."

    From cap•i•tat•ed adjective \ˈkap-ə-ˌtāt-əd\ (Medical Dictionary) Medical Definition of CAPITATED : of, relating to, participating in, or being a health-care system in which a medical provider is given a set fee per patient (as by an HMO) regardless of treatment required

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