UnitedHealth’s Optum subsidiary continues to delay mental health payments, asking for detailed information about patient histories before paying for services — despite stating publicly that it “paused” the practice of pre-payment reviews in October.
UnitedHealth’s Optum, which is in charge of certain management services like behavioral health payment authorizations, began a widespread practice last summer of pre-payment reviews, delaying mental health payments until extensive records requests were satisfied. After we wrote about this in August, an uproar ensued, and some patients stopped treatment and professional groups issued strong criticisms of the practice. Optum said in October that it had paused the practice.
But we received two new reports in the last few days of mental health clinicians who were being told a pre-payment review of documents was required for payment. And reports continue to surface of patients who are not getting paid.
One patient, two sessions
One of the new cases, from a New York psychiatrist-psychoanalyst who spoke on condition of anonymity, said she had received an order from Optum to submit all documentation for one patient seen in late November for a “pre-payment review.” The request she received, via letter, appeared to be identical to the requests we saw from therapists who sent us their letters, starting in August.
She said the request referred to one patient, with two sessions of 45 minutes each, for psychotherapy and medications. These were her first two visits with the patient, she said in a Zoom interview.
“We’re requesting medical records to complete a pre-payment review for a claim submitted for [name blacked out] … The information from the reviews will help ensure that any claim payment made is accurate,” the letter reads.
It 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. The list below details items that you should consider including, if applicable to the claim. If your medical records include any non-standard abbreviations, please provide a reference key so we can interpret the files.”
Like previous letters, it asks for treatment plans and goals, encounter and/or progress notes, UB04 billing form or Chargemaster invoice, physician signature (including credentials) for verification, medication list, superbills, claims forms, referrals, hospital records like emergency room records and admission records, and information about any lab tests, including physician orders, lab testing method, manufacturer and model of testing equipment and CLIA lab documentation, including certificates and licenses, permits etc.
Out of network
As with many other patients reported to us, this one is out of network for her. He pays her, and then he submits for reimbursement. So he won’t get his reimbursement until and unless she submits documents and they pass the Optum review process, the letter said.
Clinicians told us that the practice of extensive record collection is invasive and perhaps violates the Health Insurance Portability and Accountability Act (HIPAA) and also requirements that the “minimum necessary” standard of disclosure be met. They also said this extensive documentation requirement seems to violate the Mental Health Parity and Addiction Equity Act, which requires that insurers apply similar standards to providing medical-surgical care and behavioral health care.
She said she had been aware of the earlier mass requests from Optum, and was “relieved that I didn’t get caught up in the first request.” She also knew that the American Psychiatric Association and American Psychological Association had protested to Optum, as we reported. Optum said in October that it would “pause” the practice, the APA reported to its members.
While she was aware of the first mass request, the New York psychiatrist-psychotherapist said she had not heard of others besides herself recently required to submit documents for a pre-payment review. She also said the letter went to her old office, so there was a lag in receiving it. We heard similar reports from several other therapists, that the letter was sent to an old address.
She said she planned to talk to her patient about the topic, given that his records are the one being requested, and given that his privacy rights are at risk under the Health Insurance Portability and Accountability Act (HIPAA). She is also consulting with her lawyer. She also said she doesn’t know if the patient’s company is self-insured or fully insured.
She said she has been practicing since 2005, and has never seen such a request. As a psychiatrist and a psychoanalyst, she said, “I have the highest training you can have in mental health.”
‘Frightening’
“It is frightening to get a letter like that,” she said. “It just scares all of us. We’re trying so hard to to be good clinicians and do our paperwork and do everything right. What do they want? Are they trying to do clawbacks, or what is the goal here? The goal here, I guess, is to not pay.”
The timing of this new request is noteworthy, coming after the Manhattan street killing of Brian Thompson, the UnitedHealth chief executive officer, which set off a wave of public reaction to the role of insurers in denying healthcare spending.
The internet is aflame with people explaining how they or their loved ones were denied care and suffered awful consequences. Those people explain how UnitedHealth’s denials and any attendant consequences, now so public, should lead UnitedHealth to consider the consequences of denying payment for care, which has long been known to be a business practice that patients have documented and news organizations have reported on extensively.
We asked Optum for comment, but they did not respond. If they do, we will update this post.
Another review
Dr. Owen Muir, a New York psychiatrist who treats adults and children and also writes about healthcare at TheFrontierPsychiatrists. said he received two pre-payment review requests two weeks ago from Optum. He is out of network for both, so both patients pay him and then seek reimbursement after the fact from their insurers.
His office received the review requests by phone from people who identified themselves as working for Optum, he wrote by email. One of the phone calls was by Optum in regard to a prepayment review on a patient who has UnitedHealthcare as their employer-sponsored plan, he wrote, and the other was by Optum saying they were calling regarding a patient who has Elevance.
He said the two patients had submitted claims for both 1) evaluation and management services, which are a covered service typically without need for prior authorization, and 2) treatment with FMRI-guided accelerated transcranial magnetic stimulation, a treatment approved by the Food and Drug Administration for major depressive disorder for patients who have not responded to medications and other treatments.
He noted that this treatment, despite F.D.A. approval and peer-reviewed evidence for efficacy, is not covered by any major health plan at this time other than the Centers for Medicare and Medicaid Services agreeing to pay for it both in an inpatient psychiatric setting and in a hospital-associated outpatient clinic setting.
Evaluation and management, he said, is normally covered, even if treatment is not.
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
