Behind Graves Gilbert's issues with Humana

Graves Gilbert Clinic intends to terminate its participation in the insurance provider Humana's widely utilized Medicaid and Medicare Advantage plans — citing payments suddenly withheld, lost opportunities and a significant disregard from Humana's communications.

GGC issued the notice to terminate Oct. 17, setting a Feb. 1 end date if Humana doesn't sufficiently meet GGC's terms. GGC CEO Mike D'Eramo shared these terms and key partnership issues in an interview with the Daily News.

f"We're simply asking them to be parity with the other insurance companies," D'Eramo said, adding that "there's always room for negotiation."

"We think the items we're asking for are relatively simple, and it should be agreeable, but we've spent several months asking for the same thing, and they keep kicking the can down the road."

If the plans are terminated, most of approximately 10,000 patients about evenly split between the two plans would become out of network and would typically have three choices: finding a new health insurance plan, finding a new in-network doctor or paying out of pocket, D'Eramo said. Those with Medicare Advantage plans can choose other insurance products through Dec. 7, while Medicaid recipients aren't limited to a set enrollment window and generally can change plans through kynect. (The exception, he added, is members of groups "such as the Teachers' Retirement System of Kentucky, who have PPO plans that provide in- and out-of-network coverage at the same rate"; these benefits allow retired teachers to continue with their current doctors without disruption, he said.)

"Especially with the Medicaid population, there are options (…) to just pick another insurance product — and we'll help them pick," D'Eramo said.

D'Eramo emphasized that individuals should review their coverage and consult with their insurance agent or broker.

Asked about GGC's qualms and the potential for negotiation, Humana stated, "We are open to continuing discussions to renew our agreement with Graves Gilbert Clinic in a way that supports affordability, care quality and long-term sustainability for our members. These conversations are grounded in a shared goal: to continue providing the people we serve in Southern Kentucky with uninterrupted access to the trusted care they deserve.

"We understand that news of potential changes can be concerning. Our priority is to keep members informed and supported throughout this process. If an agreement is not reached, we will provide clear guidance and assistance to help our members continue receiving the care they need."

For the partnership to continue, GGC is expecting Humana to sign a new, more robust Medicare Advantage agreement of at least three years — rather than a one-year "watered-down" contract that was offered," D'Eramo said.

GGC asked Humana to pay back money taken without notice, to get notice and clarification about money being taken and to have local representation from Humana. These stem from ongoing issues with Humana, according to GGC.

"Will they pay their claims on time, and when they do, will they try to reclaim those dollars?" D'Eramo said. "We don't trust the financial process."

This is a constant battle, he said. An indicative instance, he said, occurred in April when Humana recouped nearly $800,000 from previously paid claims without warning, notice or opportunity for due process.

"They could have simply notified us that they were denying one claim because they believed we owed them money on another," he said. "Let's say we did make a mistake, hypothetically: Normally under a reasonable contract, a health plan would say 'Hey, we think we found an error, we need to talk about it.'

"In this case, they just reached into the corporate pocket book and said, "We're taking that money back, we're not going to pay all these claims, because you owe us this money' — and (we're) like, 'what are you talking about? Where's your data? Where's your reports? Who are you?'

"What happens is they'll more than likely pay within the 30 days, but then do an audit and say, 'Oops, gosh, there was an error — we're going to take that money back,'" De'Eramo said. "So, now the doctor (…) is taking all the risk: They've seen the patient, they've laid expenses out, they put millions of dollars of infrastructure, and notoriously Humana will come in and say: 'We found an error in an audit. We're going to take a few $100,000 back,' and you have to prove that you deserve it.

GGC added that another key issue is a lack of trust in Humana's reporting: As a provider, Humana tries to create incentives where medical providers that report high quality and low costs get a share of savings, D'Eramo said — and these come in the form of, effectively, report cards.

"When we get that 'report card,' it doesn't look like any other health plan's report card: It looks off, and it's always off in favor of the health plan — the insurance company — never off in favor of the physician," he said. "When I look at my report cards from other insurance companies … they kind of line up … It's a consistent story. But we get this report card from Humana, and it (…) doesn't line up with the other insurance plans."

D'Eramo said this has come "probably close to $1 million" in lost opportunity.

Third, D'Eramo said, is communication.

When GGC works with companies such as Anthem and Wellcare, GGC is talking to leadership — CEOs — "which tells me they care about Bowling Green," D'Eramo said. In contrast, Humana will send "a mid-manager who's retiring to take care of the conversation," he said.

Concerning the negotiations, GGC is asking for Humana to have a local representative.

"If you look at working with a health plan, they'll come to Bowling Green, they'll sit down with you, they'll work through your problems .. That's typical," D'Eramo said.

"We have regular face-to-face meetings with pretty much everybody but Humana … They'll do plenty over the phone, but they don't want to put in the time and effort to show up in Bowling Green and meet face to face."

Humana added: If members have questions or need assistance, they can call Humana's toll-free customer support line found on the back of their insurance cards."

Horowitz reports for the Daily News via a partnership with Report for America.