A professional group for psychologists reported Saturday that UnitedHealthcare’s Optum wing said it had paused its pre-payment review practice, requiring that therapists submit extensive documentation to Optum before payment for services would be made.
The American Psychological Association’s Services group, a wing of the A.P.A. that conducts advocacy, said in its newsletter and in a post on its site that the group had sent a letter to Optum, which we previously reported, and met with Optum on Oct. 10, and that Optum said it had paused the reviews.
The pre-payment reviews, affecting thousands of therapists and patients in several states, led some patients to stop treatment, and presented a huge administrative burden to psychologists, psychiatrists and other therapists. Optum started demanding treatment plans, session notes, information on any lab testing machines used for test results, and any other documents relating to the patient’s treatment. Most were out-of-network clinicians, but some were in network.
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 on Oct. 3 that it had stopped the practice, but we have abundant reports of continuing demands for extensive paperwork before payment can be made.
‘Still not paid’
Therapists across the nation continue to report that payments have been delayed, even though they submitted records, although some said they and their patients had received the payments due to them. (Optum did not respond to a weekend request for comment; we will update if they do respond.)
One Manhattan therapist wrote: “big shocking no that my clients are still not paid…2 clients and one has 9 months of sessions unpaid this year, the other is 3 months.”
Another wrote: “After hours of work they turned down one pre payment audit. They didn’t even give me the dates or why. They didn’t even say the patients name. I only knew because it was their company. The other one they turned down because they said they didn’t receive anything. They did. I have the fax to prove it.”
Another wrote that he had been filed a complaint with the Employee Benefits Security Administration about the matter.
He wrote later of his patient who had been awaiting payment: “my patient is getting partially reimbursed & now United/Optum is insisting that the insured, who is a minor on his parent’s insurance, & the parent be on the phone to discuss the situation. This sounds to me like it violates multiple privacy issues if the patient & his parent need to discuss clinical material together with an insurance employee. But I can’t get more details wihtout getting into clinical issues.”
He added: “a colleague just contacted me to say he’s being audited with a request for records but it’s being called an ‘Affordable Care Act Risk Adjustment Data’ request.” The request was from Optum, he said, seeking chart notes for an entire year. (A risk adjustment audit is different from a pre-payment audit; the risk adjustment audit uses information from clinicians to judge the severity of illnesses of plan members.)
A New Jersey psychologist wrote: “just got paid for my two pts for July and August (that I submitted on 9/13 after when I was told all claims will get paid as normal moving forward). My testing (psych eval) pt that I submit for him, but do not accept assignment (they pay him directly because he pays me directly) also received payment for these months.” She said she had no further payments outstanding.
Intermediary companies
One therapist from the Western United States wrote: “I’ve recently encountered questionable record requests through both Grow Therapy and Alma, all citing ‘Optum prepayment review’ as justification.”
Grow and Alma are among several companies that try to bridge gaps between payers, therapists and patients; therapists can register and pay monthly fees or give a cut of their pay to the company, gaining aid in billing and access to assets like credentialing, an electronic health record, a pool of patients, a telehealth platform, a scheduler and clinical assessment tools. They are growing quickly because they promise to alleviate the burden of practice management for a therapist, and can sometimes get better pay rates.
He said he signed a provider agreement with Grow in 2023, and Grow recently requested audits of seven records — all for a single patient — for claims “dating back to 2022” – but he wasn’t contracted with them until mid-2023. He said he had written written confirmation from Optum that his audit was closed, but Grow asked anyway.
With Alma, requests for records continued also, he said, though the number of cases involved was much larger.
“Optum confirmed that I was ‘in the clear’ …
“I initially handled the PPRs through Alma on behalf of Optum but became frustrated with the process and began submitting claims directly to Optum. Optum reviewed my submissions, released payment, and sent a letter confirming the audit was closed. Despite this, Alma and Grow Therapy continued to request records for the same Optum audit.”
A third company he practices with, Headway, is making records requests as part of an Anthem pre-payment review.
“What makes the Headway audit particularly interesting is that they are requesting every note again. They send the notes back with feedback, but the feedback is generic and cookie-cutter. The exact same phrases, such as ‘the note needs to be separate from another area,’ are copied and pasted repeatedly.”
He said that in all he had several hundred requests and then some duplicate requests: “Each new request takes 55 minutes to process, and each duplicate 22.5 minutes. Since June, I’ve dedicated over 386 hours — more than nine full work weeks — just to these audits. Financially, the impact is severe. Even using a conservative hourly rate of $140, the cost of processing these requests alone amounts to $54,874.17. When you factor in the lost income from reduced patient hours, the three-month impact balloons to $89,594.17.”
He said he had anecdotal reports that other Alma, Grow and Headway therapists were seeing the same problem.
A different Alma therapist said she had not been affected.
Asked about duplication of reporting, Kristina McPherson, head of strategic communications at Grow, wrote: “Grow holds the contracts with health insurance companies, making the company responsible for providing documentation related to payments when asked by insurers. Grow is contractually obligated to respond to these medical records requests. The therapists practicing with Grow rely on these contracts for their clients’ sessions to be covered by health insurance.”
What is the policy on such matters? “Grow submits claims to health insurance companies for the services provided on our platform, and is required to submit documentation for these services, when requested. When a health insurance company asks both Grow and a therapist, both need to share records in response, even if the therapist has separately submitted their records to the insurer directly.”
An Alma spokesperson wrote in an email: “Unfortunately we’re not able to comment on any specific clinical quality oversight instances. Our role at Alma is to support our community of 24,000+ providers in helping them take insurance and run their private practice, and that includes helping them navigate documentation requests from payers. This work is not always simple and straightforward, but we are committed to supporting providers every step of the way.”
Unclear picture
In its post, A.P.A. services wrote, “The PPRs primarily targeted out-of-network psychologists and mainly in five states (listed in order of most complaints): New Jersey, New York, California, Massachusetts, and Maryland.”
“A.P.A. Services coordinated advocacy with the American Psychiatric Association, especially on the joint letter to Optum (PDF, 140KB). The letter asserted serious legal and policy concerns about the PPRs, including potential violations of the mental health parity law and HIPAA, further restricting access to mental health care, and undue financial and administrative burdens on practitioners. The letter also conveyed the extreme anger and confusion that the PPRs caused our members.
“On October 10, A.P.A. Services met with Optum to discuss those concerns, as well as psychologists’ complaints about claim denials. Optum acknowledged those concerns and informed A.P.A. Services that it had paused the PPRs of psychologists. (A.P.A. Services is investigating reports, however, that Optum is still conducting PPRs of prescribing psychologists on behalf of Wellmark BCBS in Iowa, as well as other isolated reports of continued PPR problems.)
“While the company does plan to reintroduce some review of mental health claims at some point, they stated they want to work with A.P.A. Services so that psychologists are aware of the company’s documentation expectations well in advance of further reviews. A.P.A. Services urged that any future reviews should be nothing like the confusion and disruption of the recent PPRs….
“A.P.A. Services will continue to keep pressure on the company to ensure that any future reviews of psychologists’ claims are much more transparent, reasonable, and fair. If you are aware of continued Optum PPRs or have questions, contact the APA Services Legal Department.”
In response to a request to the American Psychological Association if they had reports of people not getting paid, Alan Nessman, senior special counsel, wrote in an email comment on Oct. 24: “We don’t have a clear picture yet. Generally, it seems that complaints (about non-payment or the PPRs generally) have gone way down or have stopped. We’ve seen a few isolated reports of unpaid PPR claims (beyond the exception noted below) or continued requests for records, but some reports also indicate that Optum is being more helpful than before in resolving issues.”
Is there anything else we should know? “We are aware of one instance in which Optum’s PPRs are continuing: where Optum is managing behavioral health on behalf of Wellmark BCBS in Iowa. Those PPRs seem to be focused on psychologists who have the ability to prescribe psychotropic medication under Iowa law.”
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
