UnitedHealthcare has been clawing back overpayments it says it made mistakenly to social workers and other therapists, causing havoc for many therapists and patients.
The insurance giant told therapists late last year and early this year that it had discovered it was paying licensed clinical social workers at a higher rate than what is mandated by the Centers for Medicare and Medicaid Services for Medicare Advantage enrollees, therapists and other experts said. And it wanted to be paid back.
Therapists said they were told that the overpayments had gone on for almost two years, and that they needed to immediately repay the money, in some cases thousands of dollars. The timing came before a widespread hacking event brought to its knees Change Healthcare, a payments processor owned by UnitedHealthcare, resulting in weeks and weeks of snarled payments in the healthcare system.
In many cases, to recoup what it called mistaken payments, UnitedHealthcare asked for a check in repayment, or simply withheld the money it thought was owed to it from payments to therapists — meaning that if you as a therapist saw a patient, you wouldn’t get paid, and the deductions were applied to what UHC thought you owed.
It also means that therapists receiving lower payments for Medicare Advantage patients could easily decide not to see any more, or to ask for additional payments from their patients.
From $80 to thousands
“They’re starting to claw back from like, early 2022 through the current time, so it’s thousands of dollars” for many therapists, said Susan Frager, a biller and consultant at PsychBillingCoach since 1997. She said she had heard from people owing “everything from $80 to $4,000 or $5,000,” depending on claim volume.
She said the clawback problem seems to affect out-of-network therapists for Medicare Advantage. She added that many therapists regard in-network payment rates as too low, so they choose to be out of network when possible. Frager, who has a Masters of Social Work degree, is not herself a practicing therapist.
Joanne Zumbrunnen, a licensed clinical social worker who is an adult somatic psychotherapist in Oregon, wrote in an email: “I am in network with both Medicare and United Healthcare. I have a letter requesting a recoup of ‘overpayment.’ I am submitting an appeal letter.”
In a later Zoom interview, she said that she had multiple repayment requests, all from “Recovery Services” in Atlanta, referring to Medicare Advantage patients. The requests started in December 2023, she said, and do not seem to cover all visits from those patients — so it’s puzzling what is being asked and why. She said she had been told that she was overpaid different sums — both $34 and $117 per visit — which added to the confusion.
A Chicago licensed clinical social worker wrote in an email: “I have received clawback demands from Optum on behalf of United insurance and their Medicare plans. They denied my appeal and sent a form letter not addressing either of the arguments I put forth — 1) Illinois doesn’t allow clawbacks longer than 12 months; and 2) as an out-of-network provider, I have no contract with them to accept a discounted rate. I have heard from colleagues who have appealed the clawbacks that all of a sudden Optum is requesting clinical reviews of their work — basically auditing them.
“I don’t know what I have to add … but just want to say that because of this, I am seriously thinking of no longer taking clients who have any form of Medicare — regular or Advantage. I wonder what providers Medicare-aged folks will be able to see if they don’t have the funds to pay privately for medical services.”
Appeal rejected
Another LCSW said she had appealed the clawback request. She wrote: “It feels criminal what these insurance companies are doIng to practitioners even though I’m sure they have legal loopholes that allow them to pursue a return of the money.”
In a follow-up email, she wrote: “I sent the appeal in January and they turned me down in early February. Later in February I saw the statement for my December payments and lo and behold they made the same mistake of what they believe to be overpayment from January 2022-November 2023.
“So they sent me correspondence in January saying I had been overpaid for 23 months. I appeal it. They just send a pro forma letter denying my appeal and then after that still pay me the amount they said was an overpayment for the last 23 months. It was not until I received my payments for 2024 that they actually corrected what they believe to be an overpayment.
“I only had 1 medicare advantage patient and I will never take another. But that patient dropped out of treatment once he found out about the clawback and that moving forward I would have him pay a co-pay. I think medicare advantage is a rip off for providers and patients. I think they are in a boatload of trouble moving forward. They are not medicare. They are private insurance companies with contracts ripping off the government.”
‘Huge chunk of money’
Barbara Griswold, author of the blog “Navigating the Insurance Maze,” and the book of the same name, is a therapist who helps other therapists with various aspects of the business of a practice, especially insurance. She wrote recently on her site: “One therapist forwarded a copy of the letter she received from United Healthcare Medicare Solutions/OPTUM, which asked for the return of a huge chunk of money for sessions going back two years.”
She detailed what she had heard from other therapists, including “And it seems like they are targeting out-of-network providers who bill on behalf of their clients, but network providers have also been targeted.” She suggested several appeal routes.
In her blog post on the topic, she linked to a brochure about Medicare overpayments.
No one I talked with had any success on appeals.
Some therapists have asked why they should have to immediately pay when it was a UnitedHealthcare mistake going back several years. They have also asked how they could possibly have known what the payment was supposed to be, since they are out of network — and network contracts govern in-network payments, but out-of-network therapists have no similar contracts with specified payment amounts.
Trade group complains
Anthony Estreet, CEO of the National Association of Social Workers, wrote a letter to the heads of Optum and UnitedHealthcare complaining about the issue and seeking a meeting.
“Since January 2024, Optum Recovery has been seeking overpayments from clinical social workers who were paid 100 % of the physician fee schedule when they should have been paid at 75 % as stated in section 1833(a)(1)/(F) of the Social Security Act. Overpayment ranges from hundreds to thousands of dollars. 25% is being recouped. Overpayments are occurring with clinical social work providers of Optum Medicare Advantage Plans including in-network and out-of-network providers.
“In addition, we want to bring the following to your attention:
- Members who have small solo practices are reporting they are on the verge of closing due to the burden of excessive overpayments
- Optum continues to overpay new claims
- Optum has expanded its overpayment requests
- Optum is offering loans with high interest rates for repayment
- Reassessments are being performed which have increased some overpayments
- Contracted rates have not been honored”
NASW did not respond to a request for a comment.
I asked UnitedHealthCare to explain, and their media office wrote back with a statement: “For out-of-network licensed clinical social workers, CMS has set the reimbursement rate at 75% of the CMS physician fee schedule rate. Due to an error within a claims payment system, reimbursements to out-of-network licensed social workers were made at 100% instead of 75% of the CMS physician fee schedule. Providers are required by CMS to refund overpayments in excess of the fee schedule. Extended, no-interest repayment plans are available to assist impacted providers by calling 1-800-727-6735 or emailing Recoveryicm@optum.com.“
What is the result?
It’s a challenge to find how many people are affected. Many of the therapists we talked to didn’t want us to use their names, reluctant to antagonize a giant like UnitedHealthcare and its Optum subsidiary.
We could not find any data on the extent of the problem, but judging from the number of emails I got from therapists, it’s pretty widespread. So how many therapists? Frager wrote in an email: “Everyone’s affected, because now counselors and marriage/family therapists are eligible to accept Medicare, whereas before they weren’t.”
How many patients? Apparently this is primarily Medicare Advantage, though Griswold said others are affected. “You have the people who no longer have an in-network therapist, such as in the case above. And if therapists stop practicing, stop accepting insurance, and fewer people become therapists…it affects anyone who needs mental health treatment, unless they can afford to pay cash,” Frager wrote.
“I don’t have numbers, but you get the idea, it’s not a small problem,” she added.
For the patients, do they lose their therapist, or have to pay more? “Depends on the situation but yes, happens both ways.”
For the therapists, do they have to tell their patients to find another therapist, or treat them for a rate that they never agreed to by contract? “Also depends on the situation but yes, happens both ways.”
Ghost networks
Several therapists also said that UnitedHealthcare is notoriously low-paying and that they have a harder time with UHC than with others reaching a person to reason with when they have an issue like this. They also complained that they are having a hard time leaving networks, especially Medicare ones, with UnitedHealthcare — that months and months of appeals leave them still officially in network.
“What we know is the true reason it took them 4 months to even acknowledge my notice of termination” — what is the real reason?” one therapist wrote.
She and other therapists referred to the phenomenon of the “ghost network” — a network that lists therapists who are not really accepting patients, in order to create a false number of active providers. We have written about this before: Insurers claiming a huge network that simply is not true. And because the system is so complicated, and it’s not clear to the patients (or PEOPLE, as we like to call them) who is culpable, the problem persists. Insurers claim a huge network, but doctors or therapists or other clinicians say they’re not in network, not accepting patients or something else.
Therapists say they think this is particular to the therapy business, but I’m not so sure: A well-known health journalist told me some time ago that she was seeking to have a routine screening colonoscopy done, so she called a bunch of in-network gastroenterologists. But it turned out that they would agree to do a diagnostic colonoscopy (higher paid) but not a screening colonoscopy (lower paid). Stat has written about this too, as have many others.
Others have written about this too: See here and here and here and here.
What I did hear from therapists is that they were convinced by the evidence that Plan C (Medicare Advantage) insurers were “delaying acknowledgment notices of termination of providers in order to create a false number of active providers to satisfy providership numbers required by Medicare.”
