Reimbursements for medical clinics in the North Carolina Sandhills continue to be an issue.
Several clinic owners in Moore and Cumberland counties still need to be paid for services rendered to patients who primarily come from military families.
Erin Skinner, an owner of the Thrive clinic in Southern Pines, said she faces the possibility of filing for bankruptcy.
She prides herself on giving the best nutritional advice possible to every patient she meets at the Thrive clinic.
“We opened as a group in 2021 as a group of just dietitians practicing functional medicine care,” Skinner said.
Skinner integrated primary care into their holistic medicine clinic more than a year ago to offer more services for their main clientele: military families.
The same kinds as hers. Skinner’s husband is active-duty military, and she is a veteran.
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Which is why the mom of three said she couldn’t believe getting reimbursed for providing care to this population since the start of the year has proven to be so difficult.
“Mid-January is when we realized that our claims aren't getting paid. So that's the first time that we got any idea that there was an issue,” Skinner said.
Spectrum News 1 previously reported the timeline started Jan. 1.
Clinic owners and parents alike expressed dismay at the insurer’s struggle to process claims in a timely fashion earlier this year.
Issues stemmed from a transition to third-party subcontractor PGBA.
A partial statement from Humana Military earlier this year cited that the subcontractor improperly processed Humana Military insurance claims for patients under Tricare East, the health care program designed for military families.
PGBA incorrectly filled provider portals with incorrect information like old addresses, which meant it couldn’t file claims electronically for a long time.
Skinner said as of March, they had received two claims reimbursements from Humana Military insurance with hundreds of other claims left unpaid.
She said they took out a $20,000 loan to stay financially afloat along with firing a team member.
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“The worst thing is like literally we're over $50,000 upside down this year, and we had to take out a loan to try to make payroll,” Skinner said. “We're running out of that loan.”
The nutritionist said it's not only affecting the number of patients they see each day, but it's also bleeding into her ability to see those overall because she has picked up more administrative tasks like booking appointments. Skinner said the primary care side can’t perform as many routine health checkups and other services.
“The patients are frustrated with the care not being as good and then the team is frustrated by being stretched so thin,” Skinner said.
Humana spokesperson Nan Frient confirmed advanced checks were mailed to the most vulnerable providers without defining the criteria for vulnerability.
Skinner isn’t a provider who received a check.
In the latest statement, Frient said:
“We acknowledge that our typical timeframes for processing claims have been delayed as a result of this major system transition, however, a very small percentage of claims submitted have gone beyond our contractual payment timeframe of 30 days. Claims have started flowing through the processing systems and payments have begun. We anticipate the remaining issues slowing down our claims processing and payment systems will be fixed by early March.”
A more recent development on the Humana Military website confirmed ongoing issues with processing of claims. A note was shared online on April 17:
“We want to inform you of a recently identified issue involving the incorrect processing of certain claims. Due to a system error, some network provider claims were incorrectly processed as if they were from non-network providers, causing incorrect payments. We are in the process of adjusting the impacted claims for proper payment. We appreciate your patience and understanding as we work through this as quickly as possible. Once claims have been corrected, an updated Explanation of Benefits (EOB) and remittances will be sent.”
More claims have been paid since the start of the month, but issues remain.
“Me or any other military family, after our service and everything we've done, we're not gonna be able to get quality health care like we used to be able to get, because clinics won't accept our plan because they know it won't pay,” Skinner said.
Skinner said she has received payment for about 45 claims since the start of April but more than 500 claims remain unpaid, including those from January to March.
Some clinic owners chose to tell Tricare-covered families they will have to pay up front for services and file claims on their own.
