Two professional groups representing psychologists and psychiatrists strongly condemned UnitedHealthcare’s Optum subsidiary for delaying payments for mental health treatment by demanding extensive paperwork for a “pre-payment review” (PPR) for thousands of patients, according to a letter obtained by ClearHealthCosts.
“We have grave concerns about how – during the nation’s continued mental health crisis and heightened concerns about patient privacy — these PPRs may disproportionately impact mental health patients’ access to care, and unnecessarily put their privacy at risk in a way that we believe violates the [Health Insurance Portability and Accountability Act (HIPAA)] minimum necessary rule,” Jared L. Skillings, chief of professional practice, American Psychological Association Services, Inc. and Kristen Kroeger, chief of advocacy, policy and practice advancement at the American Psychiatric Association, wrote in the letter to Dr. Amar A. Desai, C.E.O. of Optum Health, dated Oct. 8. (See text of complete letter below.)
“We write to urge that you cease nationwide the recent barrage of prepayment reviews (PPRs) that Optum has inflicted on our members.
“These PPRs have even caused some patients to stop treatment. We are also troubled by the enormous financial and administrative strains that these PPRs impose on our members, many of whom are in small practices with limited financial cushion and administrative support. Payment delays and the excessive burden of responding to these PPRs are unsustainable.
“We have had issues over the years with Optum’s practices that impact psychologists, psychiatrists and their patients but we have never seen the level of widespread frustration and outrage from our members that these PPRs have created.”
At ClearHealthCosts, we started hearing about this issue in August. We wrote on Aug. 23: “UnitedHealthcare has delayed payments to patients, psychiatrists and therapists by imposing a ‘pre-payment review’ for mental health treatment, sparking outrage among clinicians and presumably patients.” We later learned that patients, not being reimbursed, were unsurprisingly stopping treatment. A conversation with Lisa M. Gomez, the head of the Employee Benefits Security Administration under the Department of Labor, revealed that she is not certain this practice is in compliance with the Mental Health Parity and Addiction Equity Act, which requires that mental health benefits be supplied at the same level that medical-surgical benefits are supplied. Optum told us it had stopped the practice, but we have abundant reports of continuing demands for extensive paperwork before payment can be made.
Sudden change
The new letter, under the APA Services and APA logos, was posted in an online community, according to the person who sent it to us. It is not publicly visible on either the American Psychological Association Services, Inc., site or the the American Psychiatric Association site. We asked for confirmation of the letter from both groups, and also of Optum, additionally requesting comment on the issues raised, but did not hear back — perhaps unsurprisingly on a long holiday weekend coinciding with Yom Kippur, the holiest day of the year in Judaism. We will update if they respond. [Update, Oct. 15: A spokesperson for the American Psychological Association confirmed that the letter was sent Oct.8.]
How it works: Patients and therapists told us that after the therapy 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 suddenly, contrary to previous practices, under this policy change, 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. In-network claims have also been included in some cases, and in some cases the therapist gets paid by the patient and then submits for reimbursement — only to be asked for paperwork to review before payment is made.
The new letter from the professional groups says the Optum pre-payment review “standard letter seeks ‘all medical records’ that support the services at issue, for the vague purpose of ensuring that ‘any claim payment is accurate.’
“The PPRs are novel in that they heavily targeted out-of-network psychologists and psychiatrists who had not been subject to similar reviews or audits in the past. Clinicians reported that Optum had for many years been able to process mental health claims without requests for patient records.”
The letter goes on to say that the Optum policy may violate the mental health parity act. The authors write that outreach “to medical/surgical professional groups indicates that Optum’s PPRs are only impacting a narrow range of medical/surgical providers. If Optum’s PPRs are indeed targeting mental health providers more heavily than medical/surgical providers, we seriously question what parity analysis supports the application of this aggressive non-quantitative treatment limitation to such a disproportionately narrower share of medical/surgical versus mental health providers.”
The letter reports that patients are stopping or pausing treatment because they are not getting paid, which we wrote about several weeks ago. “Even where patients have not stopped treatment, the uncertainties of the PPRs impact patients. For example, one psychiatrist reported that the patient she had been treating for a serious eating disorder, who had been stable and thriving, began to experience worsening symptoms due to concerns about how she was going to afford the outstanding costs,” the letter said.
“Psychologist and psychiatrist members have also told us that these tactics have caused them to stop taking patients who are using their [out of network] insurance benefits. Those members report that they had left insurance networks to avoid these oppressive tactics, yet now, as [out of network] clinicians, they are subject to the same arduous burdens.”
The letter says American Psychological Association Services conducted an informal survey of members on the topic between late August and late September, and received more than 270 responses.
‘Minimum necessary’
“Under the HIPAA minimum necessary rule (45 CFR § 164.502(b)), Optum is obligated to seek only the minimum information necessary to accomplish the purpose for which information is sought,” the letter says. “The fact that Optum has for years been able to process [out of network] mental health claims without the extensive patient documentation it now requires before payment is a strong indication that such extensive documentation is not, in fact, necessary.”
Optum’s PPR letter (see screenshots at right), the new letter states, seeks “’all medical records that support the services’ at issue. The only stated reason for the review is the vague blanket statement that the review will ‘help ensure that any claim payment is accurate.’”
The documents Optum requested in its PPR letter include, for each claim: “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,” as well as any hospital records.
Also requested: “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.”
If the patient paid, any reimbursement will take place only after Optum receives and approves the paperwork, the letter said. If the therapist did not get paid up front, he or she will be paid only after Optum receives and approves the paperwork. Some claims date back to May, people told us.
The protest letter notes that Optum is conducting “PPRs on mental health networks of other insurers, such as Wellmark BCBS in Iowa. In those situations, the PPRs are impacting access to mental health care in the other insurers’ network.”
“In our view, Optum’s approach violates the minimum necessary standard and is particularly egregious given the sensitivity of mental health records. The standard is important in any healthcare context, but is especially crucial for mental health records, which often contain highly sensitive information that patients are not comfortable sharing with anyone other than their therapist.
“Those minimum necessary concerns are heightened further by the fact that these PPRs put a huge amount of sensitive [mental health] information in the hands of Optum, which includes Change Healthcare – the entity that just seven months ago suffered the nation’s most infamous cyberattack on health information. That connection makes both patients and their mental health professionals particularly concerned about the privacy issues here.”
Financial and administrative burdens
The letter also documents the financial burden on clinicians: “Some members reported that the PPRs delayed reimbursement significantly longer than the 9-week limit stated in the letters. In the Psychologists Survey, 44% of respondents (to a question about provider impacts of the reviews) had concerns about whether the PPRs would impact their ability to stay solvent.” Clinicians were already struggling with payment delays during the massive security breach at ChangeHealthcare, another United subsidiary, earlier this year, the letter noted.
The administrative burden, too, is not small, the letter said: “Our members have complained about the myriad ways that these reviews are burdensome, aggravating, and unfair. As one psychologist put it:
“Optum has many policies that obstruct access to help/information when you are in the process of PPR. Once I was caught between two departments who accused me of [improper billing] when I had clear proof I [to the contrary, they] offered no way to resolve the issue. I finally got to a higher up person who approved the claim but it took many hours of confusion and frustration to get paid. It was very demoralizing and costly to me.”
“Another psychologist reported having ‘passed’ the initial PPRs on multiple patients and eventually getting fully reimbursed, only to have claims for one of those patients subject to another PPR. She spent 45 minutes on hold and then another 30 minutes on the phone trying to find out why she was targeted for another PPR.
“Eventually she was told that random claims can be targeted by the algorithm for small variations in billing practices, including a minor decrease in billing (which might happen merely because the patient is sick or goes on vacation). A review or audit system that continues to harass those clinicians who have done well on the first review is deeply flawed and counterproductive.”
It concludes: “We urge Optum you [sic] to cease these onerous PPRs and take other appropriate measures to increase mental health patients’ access to in-network and OON psychologists and psychiatrists. We want to fix this problem to enhance patient access to providers of their choosing both in and outside of networks. Stopping the PPRs will also protect patient privacy, and let our clinicians focus on meeting the mental health needs of your subscribers rather than the meritless burden of these reviews.”
Dr. Jeffrey Meyerhoff, senior national medical director, Optum Behavioral Health, is cc-ed.
A.P.A. Services describes itself as the companion organization of the American Psychological Association, the nation’s largest scientific and professional nonprofit organization representing the profession of psychology, as well as over 157,000 members and affiliates who are clinicians, researchers, educators, consultants, and students in psychological science.
Still no payments
The current situation with payments is cloudy. Several therapists we are in touch with told us that payments are still delayed, although Optum told us recently that it had halted the practice of requiring pre-payment reviews.
One therapist wrote in an email: “All paperwork has been sent last month (client could not afford not to comply) and still no response from optum on outcome of ‘review’ & obviously no reimbursement for them.”
Another wrote: “Optum closed my PPR. Zero feedback. Zero addendum requests, zero deficiency notices, zero claw back or overpayment requests. … I received an unceremoniously lette [sic] that said we’re done.”
A patient told us some but not all of his delayed claims had been paid.
Several others told us theirs were still unpaid.
Optum’s email to us Oct. 3 said: “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.”
Despite this statement, both patients and therapists report that they are still waiting on payments.
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
