Guest guest Posted October 6, 2010 Report Share Posted October 6, 2010 This is an emerging topic at RehabEdge. In a word, orthonet " stinks. " http://physicaltherapy.rehabedge.com/tm.aspx?m=68961 M. Ball, PT, DPT, PhD, MBASpinal Manipulative Therapist Northeast Rehabilitation, Staff Physical Therapist Phuzion Institute for Physiotherapy Education, President and Chief Education Officer http://phuzioninstitute.com To: PTManager From: bzyheidi1@... Date: Wed, 6 Oct 2010 12:51:20 -0400 Subject: OrthoNet Just curious how everyone feels about the Orthonet/Humana situation. Is anyone else having issues with the pre-certs from Ortho-Net? We are seeing them really limit a patients visits when the medical necessity is still there according to the doctor and PT. It is very frustrating to us and patients when we call for benefits and told they have say, 60 visits a year and Orthonet will only let them use 8 of them. It seems to me when employers purchase these benefit plans, this is part of the package. (Although I know the medical necessity needs to be proven). I know its another way for insurance companies to save $ but wondered if other clinics and getting more and more frustrated with this process with Orthonet. Thanks! Heidi Harmon Billing Manager Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2010 Report Share Posted October 6, 2010 I would bet that everyone feels the same way you do. They are very frustrating to deal with and their required copays keep increasing as well. Ask for a reference # from Humana when you make the verification phone call. They will provide that and somehow, when they have to give that number out, they are much more detailed on orthonet requirements. The Humana reference # is related back to the phone call, but is not the same as the authorization number for visits obtained via Orthonet. We also have to specifically ask Humana if the eval and/or follow up visits require orthonet precert as the eval may not, but follow up appointments do. Orthonet requires a particular fax cover sheet and we have had denials if that is not sent in on the day of the evaluation. You also have to send a copy of the eval and script. We generally get 1/2 the number of visits that we request from orthonet whether we have requested 4 or 12. Read their precertification letters carefully. They will often say that visits are denied, but they approve part of the request. I would also suggest you monitor the credentialing status-we have had them not recognize providers and deny payment even when they are listed on the authorization. Good luck, Krista Krista Sheppard, PT Director of Therapy Services Orthopedic & Sports Medicine Center 2200 Fort Rd. Ste 250 Normal, IL 61761 Phone x 243 Fax kristas@... _____ From: PTManager [mailto:PTManager ] On Behalf Of @ Sent: Wednesday, October 06, 2010 11:51 AM To: PTManager Subject: OrthoNet Just curious how everyone feels about the Orthonet/Humana situation. Is anyone else having issues with the pre-certs from Ortho-Net? We are seeing them really limit a patients visits when the medical necessity is still there according to the doctor and PT. It is very frustrating to us and patients when we call for benefits and told they have say, 60 visits a year and Orthonet will only let them use 8 of them. It seems to me when employers purchase these benefit plans, this is part of the package. (Although I know the medical necessity needs to be proven). I know its another way for insurance companies to save $ but wondered if other clinics and getting more and more frustrated with this process with Orthonet. Thanks! Heidi Harmon Billing Manager Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2010 Report Share Posted October 7, 2010 We are having the same issues with Orthonet. If we ask for 12 visits, they might give us 5. So we are having to do re-evals every 5 visits or so on most of the Orthonet patients. It is very frustrating to say the least! Especially on complicated patients with a rotator cuff repair or something like that where they will need to come for a long time. We are still accepting Humana patients at this time, but my boss is so upset with them that we changed our employees' insurance carrier to BCBS. We have been telling the patients to call Humana & file complaints against Orthonet and to also let their employers know about it. That way when it comes time to renew their policies, people might feel differently about Humana. > > > > Just curious how everyone feels about the Orthonet/Humana situation. Is > anyone else having issues with the pre-certs from Ortho-Net? We are seeing > them really limit a patients visits when the medical necessity is still > there according to the doctor and PT. It is very frustrating to us and > patients when we call for benefits and told they have say, 60 visits a year > and Orthonet will only let them use 8 of them. It seems to me when employers > purchase these benefit plans, this is part of the package. (Although I know > the medical necessity needs to be proven). I know its another way for > insurance companies to save $ but wondered if other clinics and getting more > and more frustrated with this process with Orthonet. Thanks! > > Heidi Harmon > Billing Manager > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2010 Report Share Posted October 7, 2010 We have had difficulties with Orthonet as well. They have a contract with BCBS of New Hampshire and communication between both companies is poor which has resulted in Orthonet denying requests because we did not respond to their requests for supporting documentation in a timely manner. Both companies insist info should go to them first, paperwork gets lost, faxes dont arrive. Very frustrating and time consuming. Diane Maxson, MHA, MS, OTR/L Therapeutic Learning Center > > > > > > > > > Just curious how everyone feels about the Orthonet/Humana situation. Is > > anyone else having issues with the pre-certs from Ortho-Net? We are seeing > > them really limit a patients visits when the medical necessity is still > > there according to the doctor and PT. It is very frustrating to us and > > patients when we call for benefits and told they have say, 60 visits a year > > and Orthonet will only let them use 8 of them. It seems to me when employers > > purchase these benefit plans, this is part of the package. (Although I know > > the medical necessity needs to be proven). I know its another way for > > insurance companies to save $ but wondered if other clinics and getting more > > and more frustrated with this process with Orthonet. Thanks! > > > > Heidi Harmon > > Billing Manager > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2010 Report Share Posted October 7, 2010 We, too, are struggling with Orthonet, but with Cigna as the carrier. We are also telling patients to complain to Cigna. One of the other issues we have dealt with is a patient showing up as a walk in from clinic late on Friday. We often are unable to get Orthonet on the phone, and they refuse on Monday morning to back-date an approval. We have been going directly to Cigna to intervene with at least some success. Mickey Bonk, PT, MBA Administrator, Rehab Services Children's Memorial Hospital Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2010 Report Share Posted October 7, 2010 We were an in-network provider with Orthonet and United Health Care. Both organizations had burdensome administrative requirements, as you describe. That is why we are not an in-network provider with either entity today, and I am proud to say that our business has not been adversly affected by this decision. Sumesh ________________________________ To: PTManager Sent: Thu, October 7, 2010 9:44:40 AM Subject: Re: OrthoNet  We are having the same issues with Orthonet. If we ask for 12 visits, they might give us 5. So we are having to do re-evals every 5 visits or so on most of the Orthonet patients. It is very frustrating to say the least! Especially on complicated patients with a rotator cuff repair or something like that where they will need to come for a long time. We are still accepting Humana patients at this time, but my boss is so upset with them that we changed our employees' insurance carrier to BCBS. We have been telling the patients to call Humana & file complaints against Orthonet and to also let their employers know about it. That way when it comes time to renew their policies, people might feel differently about Humana. > > > > Just curious how everyone feels about the Orthonet/Humana situation. Is > anyone else having issues with the pre-certs from Ortho-Net? We are seeing > them really limit a patients visits when the medical necessity is still > there according to the doctor and PT. It is very frustrating to us and > patients when we call for benefits and told they have say, 60 visits a year > and Orthonet will only let them use 8 of them. It seems to me when employers > purchase these benefit plans, this is part of the package. (Although I know > the medical necessity needs to be proven). I know its another way for > insurance companies to save $ but wondered if other clinics and getting more > and more frustrated with this process with Orthonet. Thanks! > > Heidi Harmon > Billing Manager > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 12, 2010 Report Share Posted October 12, 2010 We are finding the problem with Humana policies replacing Medicare as they use OrthoNet. We have found success dealing with them by following the following steps. The key was following this scenario. 1) We received orders for right rotator cuff PT s/p surgery. Order was for 3 x week x 4 weeks for PROM only and then pt. to follow up with surgeon 2) We received approval for 5 visits. 3) After the patient used the first 5 visits we did the re-eval. We explained in the re-eval why they should be given the additional 7 visits. 4) OrthoNet approved 3 additional visits. 5) It was at this point that the patient appealed directly to Medicare. Medicare sent the appeal to Maximus Federal Services (they are hired by Medicare to review files and decide if the health plan made the right decision) and they ordered OrthoNet to give the additional 7 visits. 6) Pt. utilized the twelve visits and visited physician. 7) MD ordered twelve additional visits for AROM and then move to strengthening when full AROM achieved. 8) OrthoNet approved 4 visits. 9) Patient appealed to Medicare again (this time before the 4 visits were used) and Maximus sent an order to OrthoNet to approve the twelve additional visits. So, the moral of the story is (with Humana as a Medicare replacement policy).....Don't keep fooling around with OrthoNet but appeal directly to Medicare on these replacement policies. And, very important, this has worked with two other patients. Separate point: We are starting to see OrthoNet being used by a private insurer and that's a whole different problem as their is nobody to appeal to and private insurer won't back you up. Matt Capo, PT Accelerated Physical Therapy and Occupational Health, Inc Bay St. Louis and Diamondhead, Mississippi Re: OrthoNet We are having the same issues with Orthonet. If we ask for 12 visits, they might give us 5. So we are having to do re-evals every 5 visits or so on most of the Orthonet patients. It is very frustrating to say the least! Especially on complicated patients with a rotator cuff repair or something like that where they will need to come for a long time. We are still accepting Humana patients at this time, but my boss is so upset with them that we changed our employees' insurance carrier to BCBS. We have been telling the patients to call Humana & file complaints against Orthonet and to also let their employers know about it. That way when it comes time to renew their policies, people might feel differently about Humana. > > > > Just curious how everyone feels about the Orthonet/Humana situation. Is > anyone else having issues with the pre-certs from Ortho-Net? We are seeing > them really limit a patients visits when the medical necessity is still > there according to the doctor and PT. It is very frustrating to us and > patients when we call for benefits and told they have say, 60 visits a year > and Orthonet will only let them use 8 of them. It seems to me when employers > purchase these benefit plans, this is part of the package. (Although I know > the medical necessity needs to be proven). I know its another way for > insurance companies to save $ but wondered if other clinics and getting more > and more frustrated with this process with Orthonet. Thanks! > > Heidi Harmon > Billing Manager > > Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.