UnitedHealth’s Optum subsidiary told us that they were done requiring extensive paperwork before paying for mental health treatment in a “pre-payment review” policy. But we are still hearing from patients — or, as we like to call them, people — and their therapists that the reviews drag on, delaying payments.
Our earlier coverage of pre-payment reviews, starting in late August, sparked a wave of outrage, with clinicians realizing that they were not alone and that this practice was widespread. The company stopped paying some claims, saying they would be paid only after extensive records had been sent in and approved. In October, Optum told us and some professional associations that the pre-payment reviews had been paused. But that seems to be only partially true.
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.
One California Optum patient is still waiting for payment. Angela Meriquez Vázquez, a well-known Long Covid activist, linked to our earlier work on this and wrote on X-Twitter: “@Optum bullied private health info out of me and two of my out of network providers through this process. I am now refusing to comply w their demands from a 3rd provider. They denied my claim, insisting I appeal w the requested private health info.”
Ongoing health crisis
They then wrote: “@KFFHealthNews this is happening in CA and is unconscionable considering the ongoing behavioral health crisis in our state. The @APA has already called it for what it is – HIPPA and mental health parity law violations.”
Then: “What is even the point of my having a PPO plan through @UHC with out of network benefits if I can’t even get my measly $80 back for a $350 therapy session without hours on the phone and revealing my entire mental health record to some bureaucrat?”
And: “FYI if I appeal a claim & it’s denied (which I have every reason to think it will be bc no one at Optum seems clued in to the official HOLD on this pre payment review policy), my only recourse is an appeal to the TEXAS dept of health even though I and my employer are CA based.”
Next: “TX Dept of Health just kicks your complaint to a private contractor, ‘Medical Review Institute of America’ who has already denied another complaint I made about a mishandled Optum pharmacy claim bc they refused to read the additional information I and my prescriber provided”
And: “Health plans are garbage, eat the rich, starting with health plan execs”
Vázquez has long worked in education and child welfare public policy. They got Covid in 2020, which developed into Long Covid, and they have worked in several grassroots organizing efforts, including as President of Body Politic, a health justice organization and home to one of the first global Long COVID support groups. They testified on Capitol Hill and in the California Legislature about Covid, among other public health work.
Two paid, one outstanding
In a follow-up email exchange, Vázquez explained that a series of therapy visits to three different providers, all out of network, were involved. Vázquez pays the out-of-network clinicians, then submits for reimbursement from Optum. Reimbursements to them for two clinicians were paid, but one remains outstanding.
The visits to the first clinician, complicated by a crisis, from March through May, were submitted for payment in June, brought a pre-payment review notification that was mailed July 10 but not received until August, they wrote in a series of follow-up emails, with a 45-day deadline for submission of documents for review before the bills would be paid.
“I worked with Provider B (my provider) to craft a summary statement that Optum accepted and paid the claim,” they wrote.
For a second provider, claims for August were put into review, they added, and “I’m not sure what one provider ultimately sent to Optum, but that claim was ultimately paid at the appropriate out of network rate to me as a direct reimbursement (since I pay for these sessions out of pocket and make a claim for reimbursement after the fact).”
For a third provider, they said, there is still no payment.
‘Doing admin’
“this provider doesn’t do their own billing so I’m guessing the letter was received and probably not yet flagged for her. I haven’t had a chance to address it with her bc I’m ahem *in therapy* with her – I’m not trying to waste my time and precious money doing admin with/for my therapist! Esp when I now am doing this for a third time for a third provider. Optum has paid claims for this provider for the same billing codes and billed amounts for several months of claims prior and just recently paid a claim for September’s sessions. It doesn’t make any sense why this claim, why these services need additional justification.”
Do they know why? “I just think my provider has made an active effort to not engage with insurance providers for these administrative nightmares. She probably hasn’t even looked at whatever Optum sent. I’m not going to waste our precious therapy time trying to figure out what Optum needs or wants from a non contracted provider. It’s not worth the tiny reimbursement.
“Another interesting data point (and why I fully believe this is being driven by Optum’s AI algorithms) is that all 3 out of network providers who have received these pre-payment reviews from Optum have had paid claims before AND after the pre-payment reviews (I typically submit a month’s worth of services in one claim for each provider) with the exact same diagnosis and service codes.
“This is all so outrageous considering Optum is ultimately going to pay $80 for a $350 couples’ therapy session based on my out of network benefits. But I guess it’s worth it to make me work this hard for benefits I (and my employer) have already paid for, huh?”
His claims are all paid
One patient wrote by email on condition of anonymity, insisting that we not use his location or any other identifying factors: “I received the final check today 11/14 for claims that were submitted in June of this year but were blockaded by UHC/Optum under the pretense of Pre-Payment Review and demand for medical records – for which they are not entitled.
“UHC/Optum had previously approved similar claims without PPR [pre-payment review]. Additionally the practitioner had sent them the information requested for PPR but UHC/Optum never acknowledged receiving them.
“The intermediary hired by my employer to work with UHC/Optum intervened and was told on 9/13 that they would end the practice of PPR and re-process any claims held up because of PPR demands. We had two batches of claims stuck under PPR. One batch of claims was reprocessed relatively quickly, within days. For the second batch, it took two rounds of badgering by our intermediary for UHC/Optum to finally reprocess them and pay up, nearly a month. These claims were originally submitted in mid-June. All of my PPR claims are now closed and have been paid. Subsequent claims have gone through without any further difficulties….
“As you can imagine this has been a very taxing process, not to mention outrageous and potentially in violation of US law.”
Still waiting
One clinician wrote that payments had not arrived for two out of three claims in her practice that were delayed by pre-payment review.
Dr. Lauren Jessell, founder of the ParityWell group practice based in New York City, said she had received three requests for records for a pre-payment review for services received between March and July. “Services rendered were billed at $200-$350 per session. All were out-of-network claims; all were from United/Optum,” she wrote by email.
She said she submitted three for review, and only one has been paid — leaving two outstanding.
We asked Optum for comment, but they did not reply. If they do, we will update this post.
Optum pattern
This kind of payment delay is not out of the ordinary for Optum, it seems. The investigative reporting site ProPublica did an analysis this week of thousands of documents detailing Optum’s delays for mental health treatment.
“In case after case, United would refuse to cover care, leaving patients to pay out-of-pocket or go without it. The severity of their issues seemed not to matter,” Annie Waldman wrote for ProPublica.
“Around 2016, government officials began to pry open United’s black box. They found that the nation’s largest health insurance conglomerate had been using algorithms to identify providers it determined were giving too much therapy and patients it believed were receiving too much; then, the company scrutinized their cases and cut off reimbursements.
“By the end of 2021, United’s algorithm program had been deemed illegal in three states.
“But that has not stopped the company from continuing to police mental health care with arbitrary thresholds and cost-driven targets, ProPublica found, after reviewing what is effectively the company’s internal playbook for limiting and cutting therapy expenses. The insurer’s strategies are still very much alive, putting countless patients at risk of losing mental health care.”
If you have things we should know about this or any other topic, reach Jeanne Pinder at jeanne@clearhealthcosts.com or 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
