Disputing Humana’s Bogus $5 Administrative Fees

By now, most pharmacies are probably aware of Humana’s $5 administrative fees to correct, what other plans consider, educational discrepancies. We commonly see these fees assessed for incorrect prescriber (for legend drugs), invalid days’ supply, and incorrect origin code. State audit laws have been ineffective at protecting pharmacies from these clerical errors as Humana classifies these takebacks as “Administrative Fees”, not recoupments on the initial claim.

What should your pharmacy do when assessed a $5 fee?

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First, check the claims to make sure Humana is valid in their assertion. PAAS has recently seen numerous audit results where the auditor made a mistake on days’ supply, which was subsequently overturned. Auditors are not immune to mistakes with origin codes or prescribers, either.

Reviewing these fees are easy to do and should not be overlooked on appeal. These fees apply to the original fill and all refills, so a prescription with 12 fills can have $60 in fees. These fees are in addition to any discrepancy Humana may be assessing on a claim; which could lead to > 100% recoupment! PAAS recommends you dispute all recoupments, big or small.

PAAS Tips: 

  • Invalid Days’ Supply: Check the math to make sure the auditor did not make a mistake.
  • Wrong Origin Code: Double check the origin code that you billed. Does Humana’s assessment make sense?
  • Incorrect Doctor: Check the NPI billed. Is your system set up to correctly link the doctor’s name with their NPI?
  • If you find a mistake, use the Humana Corrected Values Form (CVF) to appeal the fee. This CVF should have been included with the result materials.

Remember to send your results to PAAS to have the best chance during appeal!