10 Sep Navigating Pluvicto Claim Denials: A Story of Persistence and Positive Change

In July, Radiaton Business Solutions (RBS) encountered a significant issue when claims for Pluvicto were denied by Humana due to MUE (Medically Unlikely Edits) limits. Along with these denials, recoupment letters began arriving in the mail, adding to the confusion and frustration of patients. It quickly became clear that something was wrong. 

When our implementation team member, Jean, followed up with Humana on unpaid claims, she was informed that the denials were due to exceeding the quantity allowed for Pluvicto. This came as a surprise, as the drug’s quantity had been pre-approved. At this point, Jean knew she had to dig deeper to uncover the root cause of the issue. 

Jean persisted until she spoke to the right person to take ownership of the problem. After multiple calls and discussions with supervisors, the issue was successfully escalated to a department within Humana that opened a case for review. They promised to compare the MUE rules for Pluvicto with Medicare, FDA guidelines, and their own authorization department’s standards. 

Two weeks later, Jean received confirmation that the problem was recognized, and Humana began working on fixing the system to prevent automatic denials for quantity limits. Jean didn’t stop there. She followed up with another case, pushing to have all our claims reviewed and reprocessed from as far back as last October. This included stopping upcoming recoupments and ensuring claims that were still unpaid would be reviewed and paid. 

The process took six weeks, but Jean finally began seeing the results. Claims previously denied were now being reprocessed, and the recoupments were stopped. Thus far over $200,000 in claims have been issued. While more claims are pending, Jean will continue checking daily until every claim has been successfully resolved. 

In addition to resolving our claims, Jean took a step further by asking Humana to reprocess all Pluvicto claims from other providers who may have been affected by the same issue. While Jean was not required to do this, it felt right. Cancer patients deserve the best care and support, and by ensuring other providers’ claims are reprocessed, she hopes to relieve some of the stress and financial strain caused by these denials. 

Has your practice been affected by the Pluvicto denials? Contact us; we can help.