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
- 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 http://www.merriam-webster.com/dictionary/capitated
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