Chaos and confusion continue to reign among therapists and patients as UnitedHealthcare and Optum are still delaying mental health payments for many patients and therapists by requiring extensive paperwork for what is called “a pre-payment review.”
A clinician in the Midwest wrote that he is owed more than $20,000 because of Optum’s policies of pre-payment reviews.
“Total, as of today, I have >$28,000 outstanding from insurance companies. Now a proportionally small chunk of that is the regular “wait time” as things process in the next 2-4 weeks. Ok cool. Not ideal but I understand that it’s a process. But the rest….its this stuff. United/medicad is the most sizable chunk of that balance at north of $20k. It should NEVER be this way.”
He spoke on Reddit, which is famous for its anonymity policies, so there’s no way for me to confirm these details. But it seems to have the ring of truth. And since no one else has told us the magnitude of the problem — most of the payment delays seem to be to patients, in out-of-network requests for reimbursement, so they are scattered — this is one way of trying to establish the scope of the problem.
Differing reports
Optum said on Thursday, Oct. 3, in response to our request for comment that it had changed the policy. But interviews with therapists and patients delivered widely differing reports of patients and therapists seeing no change, or partial change, and struggling to deal with the policy, which requires extensive documentation to be submitted for review of uncertain duration and with murky requirements. Both patients and therapists told us that the initial bills they sent to UnitedHealthcare are unpaid and Optum, the United subsidiary, sends a request for documents, without which the bill will not be paid. Both in-network and out-of-network clinicians are affected. (See longer Optum statement below.) Our earlier posts are here and here.
In mid-September, a New York therapist speaking on condition of anonymity responded to my query about any changes in the policy. She wrote: “Have not heard anything about relaxing/repealing, but that would be welcome news. Spoke with a number of colleagues being audited at our convention, which just ended. Right now, each provider rep that my colleagues speak with gives them a different rationale about what triggers a pre payment audit. “
Another, also on condition of anonymity, wrote: “So on background I called them last week and they admitted they were very backed up. I wouldn’t say they were soothing but I wouldn’t be surprised if they were over their heads.”
A patient reported on Oct. 1 that he had received some but not all payments for treatment for him and his wife. He lives in mid-Atlantic area, and spoke on condition of anonymity. (Most of the people who talked with me about this, both patients and therapists, said they needed to be anonymous, citing apprehension about retribution from the insurance companies, or about putting their health details online.)
He discussed the matter with his therapist, who went to Optum and was told that “the algorithm” was challenging sessions with the common Current Procedural Terminology code 90834, a 45-minute session, and requiring extensive notes. He then went to his employer’s human resources department for help. The H.R. person told him he was not alone, and he thinks that intervention may have sprung loose some of his payments.
“Some mental health claims that were held up because they were under pre-payment review have been paid – but only ones I flagged initially with my company’s insurance representative,” he wrote. It was described as “a one-time business exception.”
“There are other mental health claims that were also under prepayment review that have not been re-processed by Optum yet, and a week ago (9/24) I asked our company’s insurance representative to get them re-processed. She has not acknowledged that email and they still have not been reprocessed.
“I have filed some new mental claims for my family and I did those submissions after the apparent reversal in policy to not require additional information from the providers. Some have been processed and paid – only the ones involving a therapist we’ve used previously. We have some new providers and I filed claims last about 10 days ago that have not yet been fully processed.”
“The amount of hours i have spent on this is untold,” he said in a phone interview.
Compliance score
Yet another version came from a New York therapist who forwarded an email from an informal listserv he is on from a big New York institution on Oct. 1, prefacing it by writing:
“That docs have to do what’s described below is completely inappropriate & crazy.
“That the docs are going along with is is also a collusion with a pathogenic situation, devaluing their own expertise & the treatment, allowing an external administrative cloud to alter the treatment & their role as a doctor.”
The listserv email he forwarded is titled “How to stop Optum med records requests.” It reads: “For those of you being audited:
“Once you start complying with sending records, you can do this every 60 days. It is possible you have to wait 90 days the first time before requesting this (below) however then you can do it every 60 days until you get the 80% score and the audit will stop.
“Call provider services at 877-972-8844. That is the PNI department (whatever that means). You’ll need to give your EIN / tax ID so they locate you as a provider.
“When you get a rep on the line: request they run your compliance score. It will take 24-72 hours for Optum to run your number.
“If you are at 80% or above they will stop this audit for your practice.
“You can ask them to email you or you can simply call back to find out the result and what your number is.
“You can also ask them to send the report to you so you can see exactly what’s going on with what you’ve submitted to substantiate your score.”
He added “the email is from a helpful, or well-intentioned, clinician in private practice” and then wrote “I am disappointed that my colleagues are cooperating & don’t recognize that the ‘solutions’ validate & perpetuate the problem “
Another New York therapist wrote “no news yet and i dont think my clients have been paid to date. Very distressing “
Yet another version
Another version of events came from a New Jersey therapist who said they had been told the pre-payment review policy was “on hold,” and that “Anyone who has had claims denied, whether or not they submitted records, need to call to have those claims reprocessed. If the representative you speak to does not understand (if they are not aware of this policy, what has been going on, and what they need to do), then simply ask that this claim be “escalated;” the “back-end team” will know what to do with these once-denied claims to get the processed.”
None of this was officially conveyed in writing, just by phone. Of course this puts the burden on the therapist to ask again to be paid. They added: “Stay tuned! I would really want confirmation of my claims (and those of others) being processed before any positive affirmations are publicly made.”
They said in late September they had received payments for sessions in June that were under pre-payment review, and then wrote that the American Psychological Association “is actually actively working on this issue, because according to them, this is NOT resolved and/or over…. Not sure why different people are being told different things.”
A Redditor wrote: “This happened to me, and I’m in network. They held one client’s claims up by almost two months and then finally processed and paid them. Meanwhile, my client delayed his treatment for those two months, not knowing if his insurance would pay or if he’d be responsible for hundreds of dollars of services that were covered. I tell people United held my claims hostage, because that is most accurate. My client called and they told him they were waiting on his provider to send information. I kept calling them and asking if they needed records or anything from me and they just responded no there’s nothing we need from you, you just have to wait. And at some point told me to stop calling them.”
United says it changed policy
I asked United-Optum:
1. Is this policy a violation of the Mental Health Parity and Addiction Equity Act?
2. How many therapists and patients are in the pre-payment review process now? And in what locales?
3. Is any change in this policy envisioned, and if so, what would it be and what is the timeline?
4. If no changes are envisioned, do you have any suggestions for patients or therapists who are not getting paid for things they believe are covered by their UHG-Optum contracts?
The response, on Oct. 3:
“On the record statement:
“We follow all state and federal laws, including the Federal Mental Health Parity Act. We encourage any provider with questions about a pre-payment review request to contact us at (877) 972-8844.
“Additional info on background:
“Impacted claims are being released and reprocessed; no further action is required from the member or provider.
“Earlier this year we incorporated Commercial psychotherapy claims into our existing pre-payment review process for both in-network and out-of-network providers.
“Based on feedback from providers and members, we paused reviews for these psychotherapy codes in late August.”
Multiple United visitors
We have seen multiple visits to our site from UnitedHealthcare via our web analytics. We also noticed that the article has been posted to a number of groups.io accounts, and to UnitedHealthcare’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.)
New York State visitors to our site looked at the posts about UnitedHealthcare delaying payments. The time per visit, more than 14 minutes, is very high by web standards.
My post about patients abandoning or delaying therapy because of pre-payment reviews was featured in a keynote address in mid-September at the New York State Psychological Association’s convention in Saratoga Springs, N.Y., an attendee wrote in an email. The speaker who used the link in a slide was Dr. Marnie Shanbhag, the American Psychological Association’s senior director for the Office of Independent Practice. She is quoted in the post.
Previous UHC case
This is not the first time UnitedHealthcare has come under fire for denying mental health treatment.
“In a scathing decision released Tuesday, a federal judge in Northern California ruled that a unit of UnitedHealth Group, the giant health insurer, had created internal policies aimed at effectively discriminating against patients with mental health and substance abuse disorders to save money,” Reed Abelson wrote in The New York Times in 2019.
“U.S. Chief Magistrate Judge Joseph C. Spero found that United Behavioral Health, the insurer’s unit that administers treatments for mental illness and addiction in private health plans, had violated its fiduciary duty under federal law.
“‘There is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions,’ he said. He dismissed much of the testimony by UnitedHealth’s experts as ‘evasive — and even deceptive.’ ” United Behavioral Health was ordered to reprocess the claims in question.
What you can do
Lisa M. Gomez, assistant secretary for employee benefits, is the head of the Employee Benefits Security Administration in the Department of Labor. She discussed our reports on UnitedHealthcare-Optum withholding therapy payments in a Zoom interview in which she said such actions might be a violation of the M.H.P.A.E.A. Find that post here.
She said there is a hotline for E.B.S.A. at 866-444-3272 and an email message form and resource center at this link. The phone and emails are able to talk in multiple languages.
M.H.P.A.E.A. resources from E.B.S.A. like fact sheets can be found on this page.
June Feder, a psychologist practicing in Manhattan who is chair of the New York State Psychological Association insurance committee, 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). Some insurance plans are governed by federal law (Medicare and self-insured employers under ERISA) and some by state law (fully insured).
Other suggestions for individual practices are towards the end of our previous posts on this topic, see here and here.
If you have information about insurance payments for mental health care, or other issues you think we might want to know about, email jeanne@clearhealthcosts.com or use our secure Signal at 914-450-9499.
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
