Insurance and one puzzling question…

In late December 2008, I decided I wanted to be a Humana Primary Care provider. I requested a credentialing packet, filled it out and sent it in. Early March, I received feedback/phone call from Bauer (not real name) requesting “clarification” as to what I was intending to do. She says, “I’m not sure what you are trying to do.” I said, ” I am requesting to become a PCP/NP with your insurance company.” She then said, very politely, “Well, Dr. Baker we just don’t do that. We don’t credential NP’s. Is this for you or your collaborator? I mean…we can link you to him and give him a second location??” So, I politely, say, “No maam…this is for me-the NP (I direct her to my website for clarification) to enable me to adequately serve my current Humana patients (who pay CASH to see me) and the new patients requesting my Housecall services.” We hang up and I don’t hear from her for a week.

Now, I decide I need to be forthcoming and a tad pushy. So, I begin calling Bauer every week. In my weekly calls, I gently ask her for status updates and overall progress in which she was always “waiting” on her boss to respond. Three weeks into my weekly call protocol, I start giving her the names of patients who are dis-enrolling from Humana because I am not a provider on their plan. I also start telling her that we are getting referrals from Humana clients on a daily basis, BUT since we are not on the provider list…sorry, they are told to find services elsewhere or dis-enroll. The final straw came when a Humana rep was in one of my patient’s homes and the patient said that they were not switching their plan to a HMO unless Dr. Scharmaine was on the plan. So, the rep calls my office and I give her an ear full as well as what has or has not been going on with Bauer. This rep then calls Bauer as if I had given her a fable or something. Later that day, Bauer calls me and says, “Dr. Baker, let me be clear. It’s not that we don’t want to add your practice. WE HAVE NEVER BEEN APPROACHED BY AN NP AND WE DON’T KNOW WHAT TO DO!” What! I said, “Ok. Well, where do we go from here?” “Let me get back with you, ” she says.

It is now Mid-April, I get a call from Bauer and she says, “we’ve got the green light to add you, BUT we don’t know what to call you?” “What?!”, I say. Bauer says, “I mean you would not be classified as ancillary and you are not a physician.” I say, “Why not call me a nurse practitioner?” “Let me get back to you, ” she says. Two more weeks pass and it is now late April when I receive a call from Bauer, she states, “We will figure out the particulars as far as what to call you or classify you as , but you will be a provider with a number.”

Today, six months later, I received a call from Bauer stating that I will be a participating provider with Humana beginning June 1st, 2009 as a Nurse Practitioner.

Take Home:

The moral of this true story is to never give up and keep pushing for the wall of resistance to break. It also helps to really-really want something because this passion will fuel your spirits when things are not happening as fast as you want them to.

It also helps to have a website or other marketing tools to give to the public, vendors, or political allies. This will not only show them that you are a serious contender, but it gives them something tangible to refer back to especially when they are not sure of “what” to call you. I say eliminate the guessing game…show and tell everyone that we are nurse practitioners and we are not going anywhere.

11 responses to “Insurance and one puzzling question…

  1. Nancy Leigh Harless

    Scharmaine – You are such an inspiration! I am in awe of you and all you are doing to promote the NPs’ when i say it I mean it — I hold you in AWE!

    ~ Nancy

  2. Congratulations on your efforts! It may only be one at a time but we all can collectively learn from this and decrease the barriers to NP practice.

  3. chroniclesofababycatcher

    I just find it so weird that Humana- a substantial health plan- would not have ANY NP’s as primary care providers? I’m glad you persevered though!

  4. Wow! I know I’m really late to this, not sure if you are still updating this or not. I have had the exact same problem. I started my own practice July last year. I make “housecalls” to residents in assisted living facilities and independent living communities for seniors. It is an underserved population with no one else here in Knoxville willing to do this. Humana, who has a nice chunk of the Medicare Advantage patients here, will not credential a solo nurse practitioner. I’ve gotten the same run around. Evidently, I need to be more persistent!

  5. I am interested in starting a practice in MS any suggestions?????

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