A number of psychotherapy patients in the Northeast have stopped treatment because their insurer, UnitedHealthcare, is requiring substantial paperwork for what it calls a “pre-payment review” that has stopped reimbursements, therapists say.
The interruption in treatment comes after UnitedHealthcare’s Optum subsidiary began subjecting thousands of payments to a “pre-payment audit” in the last several months, the therapists say. After the visit takes place, the out-of-network psychiatrist or therapist is paid by the patient (usually) and the patient submits the bill for reimbursement, to UnitedHealthcare. But Optum, the subsidiary managing health services for UnitedHealthcare, sends a letter to clinician and patient saying it wants detailed records for a “pre-payment review” before sending money. No reason is given. (Our earlier post here.)
“The impact of these reviews is raising concerns about delays in treatment (since many pts are holding off on additional sessions out of fear that the treatment will not be covered), patient privacy, delays in reimbursement, and unnecessary additional administrative burdens on psychologists,” wrote Dr. Jax Gallios, an out-of-network psychologist in New Jersey who submits bills to United on behalf of some of her patients. “It is also raising parity concerns, including further constriction of the already difficult access to mental health care through insurance.”
Gallios said “people STILL haven’t heard back after submitting records for the massive influx of pre-payment review requests — they have up to 45 days to respond to providers after documents have been mailed. I personally haven’t heard either.”
‘Very destructive’
June Feder, a psychologist practicing in Manhattan who is chair of the New York State Psychological Association insurance committee, said others are stopping too.
“Some have notified psychologists they cannot continue treatment because they are not getting reimbursements,” she said in a phone interview. “It’s very destructive.”
A Connecticut psychologist who spoke on condition of anonymity said she also has a patient who is pausing treatment, though she told the patient “I don’t think it’s best” to stop.
It’s not only patients cutting back, but also clinicians.
A West Coast therapist wrote: “I’ve had to reduce my schedule to 60% capacity” to meet the administrative burden. He said he had received dozens of record requests, followed by dozens of duplicate requests.
“Each new request takes 55 minutes to process, and each duplicate 22.5 minutes,” he wrote.
Reports are anecdotal so it’s hard to say how many patients and therapists have quit or cut back. But if patients who paid for services expecting insurance reimbursement are not getting paid (at least one has not been paid since May) and clinicians submitting bills and expecting payment are not getting paid, then it is easy to see how things might shut down.
Other billing challenges
For patients and clinicians, the context of the payment delays also matters. “The thing that I want to underline is that this is coming on the heels of what has been a very difficult period,” said Dr. Marnie Shanbhag, a Florida licensed psychologist who is the American Psychological Association’s senior director of the office of independent practice. “We have not seen demand for mental health services let up since the pandemic, when the demand really did soar. I think we we all understand that people were very stressed out during that period and and are still coping with the fallout.”
The payment delays are particularly damaging to therapists because of the timing, Shanbhag said.
At the turn of the year, many practices encountered delayed payments because of an update in medical coding practices for Medicare, she said. Once the systems were updated and payments began flowing again, the massive Change Healthcare data breach took place, and payments stopped again. And now these pre-payment delays are further stressing psychology practices.
“Providers are really feeling like they’re at the end of the proverbial road in dealing with just one thing after another, all of which seems to delay payment,” she said. “Much of mental health care in this country is provided through small, individually owned or small-group independent practices, so they don’t always have large resources and reserve funding that maybe hospital systems, etc. might have.”
The pre-payment reviews were seen before the pandemic, Shanbhag said. They were not that common for a while, she said, but then recently the A.P.A. started hearing large numbers of pre-payment reviews, currently primarily centered in New York, New Jersey and Maryland. It seems to be affecting out-of-network psychologists more than in-network, but both are affected, she said.
‘Unnecessary burdens’
“It’s particularly frustrating because nobody wants to engage in unnecessary administrative burdens,” she said. “When you are out of network, you’ve essentially chosen not to participate in an insurance system for all kinds of reasons. One might be, you don’t want to engage in this kind of administrative work that is overwhelmingly uncompensated.
“So it really puts you in this very difficult position vis-a-vis your patient and the insurance company. Here’s an insurance company that you have not contracted with, and you’ve often been paid by your patient, but in order for your patient to recover some partial reimbursement from the insurance company, they are being asked to have the provider do this. And we don’t want to create additional burdens for our patients. A company that you are not contracted with is now requiring you to do things. If you say no, you’re worried you’re going to hurt your patient.”
Another issue is the insurance companies’ specific demands, she said.
“We are not privy to the documentation requirements for these insurance companies because we are not contracted with them,” she said. “So they may choose to flag certain records or deny certain record claims because of inadequate documentation, but we are not educated about those documentation requirements because we’re not on contract.
“Often the things that they flag seem to be incredibly minor things that don’t actually affect quality of treatment provided. For example, insurance companies love to make sure that records have start and stop times. We will often say in the record ’45 minute session.’ But really what they want to know is that the session, let’s say it was a 2 P.M. session. It actually started at 2:04 and it ended at 2:49, and you can imagine the kind of minutia record-keeping that would require, in a day that you’re seeing back-to-back patients. And the start and stop time really doesn’t affect the quality of the care.
“Also, let’s say I signed the record ‘Marnie Shanbhag,’ but I didn’t say ‘Marnie Shanbhag, licensed psychologist’ in my signature, even though the note itself is on an office form that says ‘Dr. Marnie Shanbhag, licensed psychologist’ with with my license number on that form. It isn’t even that the page is missing that information. It’s just that they wanted the handwriting of the signature to include that information. Again, not something that we would say affects the quality of care.”
Also, she said, an out-of-network psychologist has great difficulty in calling an insurance company to explain or reason with someone. If you’re out of network, the phone tree doesn’t work. “It’s a tremendous barrier,” she said.
She said the A.P.A.is collecting information about the scope of the payment delays, and after that will determine a course of action.
Will the A.P.A. have a response as a group? “Normally in those kind of situations, A.P.A. would not have an official policy on a concept like a prepayment review, because our practices are all individually owned by by psychologists,” she said. “They’re not owned by us, and the contractual relationships between the insurance companies and the practices are really outside of our purview. But we certainly try to contact insurance companies and do what we can to understand the issues and to help members navigate.”
“Historically, what I can say is that when we reach out to insurance companies, generally speaking, we often end up with more questions than answers. Many times they’ll want a list of providers and patients to begin that process. So you can understand that for our providers, it’s a very anxiety-provoking issue, and and they don’t always want to be identified, given that they worry feeling targeted in these kind of situations.”
UnitedHealthcare response
We sent these questions to UnitedHealthcare, asking about patients stopping treatment, but got no response. We will update if they answer.
“1. Was this result envisioned under the pre-payment review policy?
“2. Do you have advice for patients or therapists who are seeing this happening in real time and expecting possibly dire consequences? The therapists we have spoken with say they are complying with these often onerous records requests, but payments are still not being made.
“3. Is this a violation of the Mental Health Parity and Addiction Equity Act?
“4. How many therapists and patients are in the pre-payment review process now?”
The Optum letter to clinicians about the pre-payment review asks for “all medical records that support the service(s) provided to this patient on the date(s) of service covered in the claim submission.”
Items listed include “Office visits: All available documentation for the services rendered, including but not limited to: Encounter and/or progress notes, treatment plans and goals, medication list (prescribed or managed), superbills, claims forms, referrals, UB04 form or chargemaster invoice of CPT/HCPCS codes corresponding to the revenue code, physician signature (including credentials) for verification, any other documentation regarding care that may assist us in our review of the services rendered and services billed.
“Initial inpatient or hospital request: Emergency room records, admission records (initial patient intake form, face sheet, nursing assessment, inpatient physician order, initial intake visit, etc.), discharge summary.
“Lab claims: Physician’s orders for the laboratory test, including any standing orders and/or provider custom panel orders, whether for the ordering provider or all referring providers, laboratory testing method, specimen type and test results related to all billed services, CLIA documentation (certificates, licenses, permits, etc.), manufacturer and model number of the testing equipment used for billed services, manufacturer and brand information for all test supplies used for billed services.”
“The claim is on hold until records are received,” the letter says, saying a review will begin that could take 30-45 business days. If the claim is supported, it will be processed; “if the requested medical records are not received by the deadline, the claim will be denied.”
N.Y.S.P.A. experiences
Feder, the New York psychologist, said in an interview that she is speaking for herself and not for N.Y.S.P.A. on what N.Y.S.P.A. has learned.
The pre-payment audit is not new, she said — it certainly was present before the pandemic, and N.Y.S.P.A. worked with members to try to get information.
“The major difference is the number of people who are affected now,” she said in a phone interview. “It is massive. it is not just psychologists. It’s psychiatrists, social workers.
“It’s a flood. Not just in New York, but other states also — Rhode Island, New Jersey and Iowa, we hear through our national organization.”
Pre-pandemic they dealt with 10 people who had pre-payment review requests over the course of several months, she said. “Now, since the first week in August, we have had over 50 people who contacted us,” she said in late August. She thinks that the actual number is bigger; there are 12,000 psychologists in New York state, and not all are N.Y.S.P.A. members. “There are many many more,” she predicted. “They are both in-network and out-of-network,” with two-thirds out of network and one-third in network, “who are paid not sufficiently to begin with.”
It’s currently almost all UnitedHealthcare-Optum, she said, though there is one person who got such a message from Blue Cross Blue Shield.
The impact has been noticeable, she said: “hours spent on the phone trying to get hold of somebody who can be helpful to them” plus concerns about privacy for patients.
She also said she is “concerned that behavioral health people are getting targeted” — while the Mental Health Parity and Addiction Equity Act requires that behavioral health treatment be covered in parity with medical-surgical treatment.
“On medical health, it’s not that they aren’t getting targeted, but I haven’t heard anything to this degree.”
On Monday, acknowledging that the parity act was not consistently being observed, the Biden administration finalized a regulation to enforce it. The rule “is requiring health insurers to evaluate which mental health providers’ services are covered by their plans, how much those providers are paid, as well as on how often they require or deny prior authorizations for coverage,” Reuters reported.
Further surveys
Both N.Y.S.P.A. and the A.P.A. are surveying members to gather data, Feder said.
Asked what she would like to see in her crystal ball, she followed up after the phone interview with this list:
- “Patient access to mental health services which they are contractually entitled to receive
- “Adequate reimbursement;
- “Protection of patient clinical data and privacy related to questionable insurer information release requests;
- “Regulatory oversight of pre-payment audits which deprive providers of timely reimbursement for delivered services and increase risks of treatment disruption for vulnerable patients.”
Many UHC visitors
The post we wrote on the problem sent our traffic through the roof, and now, more than two weeks later, we are still seeing that it has been re-posted and emailed to other recipients.
Via our web analytics, we saw many, many visitors from UnitedHealthcare and Medica Health Plans. Also two visitors from the U.S. Senate. We also noticed that the article has been posted to a number of groups.io accounts, and to United’s Microsoft Teams account. (This particular function of our analytics shows us the origin of the visitor in some cases, depending on how the internet setup is configured. Pre-pandemic, it was very rich; now it’s a shadow of its former self, because so many people are working remotely and the analytics show only the carrier name — Verizon Fios, Comcast Cable, Cincinnati Bell, for example.)
The piece has been posted on multiple Facebook, Reddit and LinkedIn accounts, and flagged on X Twitter. It has shown up on listservs for therapists in North Carolina and Minnesota and elsewhere.
One psychologist posted it on his site in a section about why he limits his participation in insurance, and what that might mean for a patient. “For many of the above reasons, I have limited the number of insurance carriers with which I agree to participate. Accordingly, it is best to speak with me prior to scheduling your first appointment to discuss details. We certainly can still work together even if I am not on your particular insurance panel.”
What you can do
So what can you do?
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 in a piece titled “Out-of-Network Audits: FAQs and Protective Actions You Can Take NOW”: “After reading my recent article about out-of-network records requests from insurance plans (if you missed that article, click here), many readers responded with versions of ‘do I HAVE to deal with records requests? I didn’t join this insurance plan!’ They expressed outrage, but also concern that their notes were not legible, were only readable to them, or just would not meet insurance plan criteria.
“The most frequently asked questions were:
“Can I put in my informed consent that I won’t give out ANY superbills, so I don’t open the door to audits, and don’t have to worry about all this?”
“Can I refuse to turn over my records, if they are requested?”
“Can I just send a treatment summary?”
“Can I just refuse to give superbills to clients who have certain health plans, if I know the plan audits a lot?”
She then gives answers to these questions in her post. Griswold also gives webinars on such topics and she consults with individuals to help them resolve problems.
Feder also suggested that people wanting to make legislators and regulators aware of this speak to their state and federal elected representatives, as well as complaining to the Department of Financial Services (the New York D.F.S. complaint site is here) or the attorney general (the New York A.G. complaint site is here).
Others in our series:
UnitedHealthcare delays mental health payments, causing outrage
Therapy patients stop treatment after ‘pre-payment reviews’ swell
UnitedHealth-Optum payment delays for therapy may violate mental health parity, official says
Optum squeezes patients and clinicians further in ‘pre-payment review’ delays
UnitedHealthcare’s Optum strongly criticized by psychologist, psychiatrist groups
UnitedHealth’s Optum says it has stopped delaying therapy payments, though many are still unpaid
UnitedHealth’s Optum pre-payment reviews drag on, though company says they are over
UnitedHealth’s Optum continues mental health payment delays, despite saying they have ended
Insurers’ wide payment reviews drive therapy practices to despair
