A Los Angeles company that offers comprehensive mental health treatment is “teetering on the edge of shutting down,” with $400,000 worth of unpaid claims from insurers during multiple payment reviews. A New York City therapy practice has been waiting for months for $90,000 in payments delayed by a pre-payment review from Blue Cross Blue Shield.
A practice treating children in Atlanta has seen its payments delayed by pre-payment reviews from two insurance companies, threatening it with shutdown. A solo practitioner in California found himself in pre-payment reviews that were so onerous he decided to close his practice and instead go to work at a non-profit hospital.
The therapists and one practice manager all described a Kafka-esque process: They deliver treatment and submit bills for reimbursement, but then are told they are in pre-payment review, meaning no payments until they pass some insurance review process. They tell of being asked repeatedly for more and more details about therapy visits, which they felt they’d satisfied. But the insurance companies told them that they needed to send more records or different records — or they were told that what they had sent had not been received, even though they had fax receipts and multiple phone calls and emails attempting to resolve the problems over months.
The practice of pre-payment review has soared in recent years, with several insurance companies claiming that they need extensive documentation to be sure mental health treatments were warranted and effective, instead of paying without friction.
Representatives of three practices spoke on condition of anonymity because they said they were afraid that insurance companies would punish them if they were too vocal about what they see is unfair treatment. The fourth, Ben Spielberg, is the C.E.O. of Bespoke Treatment in Los Angeles, which offers comprehensive treatment, including treatment for patients with treatment-resistant depression. He agreed to have his name used, writing: “You are welcome to name me — I’m pretty much at my wits’ end.”
When we first started writing about pre-payment reviews for mental health treatment last August, we eventually heard from United’s Optum that they had discontinued the practice. But we keep hearing from people that not only Optum, but also other insurers, continued, some with great intensity.
We have asked all the insurers in this post for comment, but no one supplied a comment. We will update if they do.
New York group practice
The New York City group practice has around 15 therapists, and around 300 patients, the practice manager said in a Zoom interview. A total of 190 claims were challenged.
Blue Cross Blue Shield is by far and away the most used Insurance in their practice. Their prepayment review begin in early November, the practice manager said. Some claims were approved and paid, maybe about 60 percent, he thought, but they are not timely — they’re not within the 30-day window that is mandated. Many on the other hand have still been rejected, he said, about 40 percent.
“With that type of over-reliance on a payer, it’s very difficult to financially keep the practice going, ” he said. “We have to meet payroll. Clinicians — we had a few that left because they were just very frustrated with documentation requests.”
He said the practice sent the insurer detailed notes, which were rejected. When he asked what they were supposed to send instead, he said, they referred him to Blue Cross Blue Shield guidelines for psychotherapy reimbursement. “a summary of progress or lack thereof, to identify omissions to correct.” When they reject the claim, they put this line in “summary of progress or lack thereof toward identified goals. Lack of progress should result in change in plan or new plan of care.”
He has asked for a conversation about what was lacking, but he said Blue Cross did not want to do that.
He said most of the sessions that are being audited are for Current Procedural Terminology code 90837, which is for 53 minutes and above.
He also said it seemed completely arbitrary: “You have 10 dates of service, same therapist, same format, and seven are accepted. Three are rejected.”
The therapist who started this private practice in 2016 grew it into the group practice. She is a licensed mental health counselor and a licensed professional counselor certified in New Jersey and New York.
Children with autism
One group practice in the South has been slammed by prepayment reviews by UnitedHealth’s Optum and Blue Cross Tennessee. The owner, who uses applied behavior analysis for children with autism, said she began facing issues in March 2023 with Optum, where she had a 31 percent pass rate on her reviews, meaning she was paid for 31 percent of claims, and had to discharge 20 UnitedHealth clients due to unpaid claims totaling around $25,000.
With United-Optum, she said, the process was confusing in the extreme. She got the letter saying she was under pre-payment review, “and I was thinking, O.K., you send your records over and they’ll pay you. But no, it didn’t quite go like that — first of all, I didn’t receive a letter for every claim. There are so many things they don’t have written down for you, like there’s nothing anywhere that says, ‘you have to wait until we request the records.'”
“I called Optum multiple times, and I had different people tell me different things I need to do. Like one person would say, ‘Oh, I’m going to reprocess.’ And then I call back to check on it, and somebody was like, ‘Oh, she shouldn’t have told you that — that’s not how you do it. You need to write a letter. You can put this reference number on it.”
“It took months for me to finally get a supervisor on the line to send me a spreadsheet so that I would know each claim I needed to fix, and that’s kind of how we got on track.”
Because she wasn’t getting paid, she discharged those 20 UnitedHealth clients, nearly half of her client base.
A new round
And then she faced a new process with Blue Cross starting in January 2024, leading to further unpaid claims, totaling $70,000.
She said she got inconsistent instructions from three separate people at Blue Cross, beginning with the statement that this pre-payment review was a new process, and “instructions would be forthcoming.” She finally learned from the mother of one of her clients that Blue Cross wanted records, but the type of records was not specified.
After months of waiting, and fruitless calls, she said, one day she called Blue Cross and they said the entire process would go through a company named Cotiviti, which says on its website: “Cotiviti helps consumers to protect their benefits by working to ensure their healthcare bills are paid appropriately and reduce fraud, waste, and abuse. Our solutions are not leveraged to deny care or question the medical determinations of providers, but rather to help avoid paying erroneous claims that unnecessarily inflate healthcare spending.”
Despite multiple attempts to resolve issues, she was eventually removed from the Blue Cross network in October 2024. “I was told I was being kicked out of the network for refusing to bill claims due to the financial hardship created by the prepayment audit,” she wrote in an email. “I have practically gone bankrupt. It was really a slap in the face.”
California practice
Spielberg, the C.E.O. at Bespoke, wrote that he has been dealing with a pre-payment review from Anthem since November, “and the investigator doesn’t seem particularly motivated to remove us from the review — even though we have fixed all of the issues that were identified.’
One of the treatments Bespoke uses is therapy with Spravato (esketamine), a nasal spray medication used for treatment-resistant depression, which is available only at a certified doctor’s office or clinic.
Spielberg said Bespoke has five prescribers and four therapists for 1,300 patients. The unpaid claims in review total about $400,000 to $500,000, between Anthem and Aetna, he wrote: “Our affiliated medical group has had to take on a line of credit to keep us afloat, but we are almost maxed out. We are teetering on the edge of shutting down because of these issues.”
Spielberg said Anthem put Bespoke on a review in October 2023, with a range of issues. They followed Anthem’s direction, and received a clearance in 2024, saying that no further action would be taken by Anthem.
“Then, seemingly out of nowhere, we received a letter on November 5, 2024,” he wrote. “The letter stated that we were being put under P.P.R. for reasons including lack of consent forms (which we offered to Anthem in February 2024, but they declined to accept), inappropriate telehealth modifiers, and a lack of diagnosis on each [Transcranial magnetic stimulation] note. These were all issues that we fixed — with the help of the investigator at Anthem — back in February 2024. There was no new record request, just straight to P.P.R.
“When the review started, all of our claims passed except for two types of claims: they wanted start/stop times for psychotherapy that occurred during medication management appointments, and the bigger issue was that all of our Spravato specialty pharmacy claims were denied for not including proof of the medication. When you bill Spravato under specialty pharmacy, that means that the insurance company pays for Spravato, and it is sent to the provider’s office for administration and ongoing monitoring. Basically, Anthem paid for the medication, but dinged us for months for not including proof that we monitored the medication — even though they know full well that they paid for the medication for this patient, and that the patient didn’t do it anywhere else.
“To Anthem’s credit, they have at least been somewhat responsive and have been somewhat amenable to working with us. They have taken some codes off the P.P.R. (although they’ve added others as well). Nevertheless, these are not issues of fraud, waste, and abuse. These are basic clerical issues that Anthem is using as a weapon in which payment can be perpetually delayed in the hopes that providers like us simply decide to stop treating Anthem patients — at least, the hope is that we decide to stop treating Anthem patients who rightfully use their insurance.”
Aetna review
Then Aetna chimed in, Spielberg wrote, first with a request for records for a handful of patients, most in intensive out-patient (I.O.P.) levels of care. Aetna sent a routine records request to Bespoke Treatment on Aug. 5, 2024, requesting records for a handful of patients who were mostly in IOP levels of care, he wrote.
Then, “On November 22, 2024, Aetna sent a notice putting us on P.P.R. with the following language: ‘Our review of the medical records received by your office indicates that you are prescribing and performing ketamine-assisted psychotherapy. According to Aetna’s Clinical Policy Bulletins (CPBs) 00938, Ketamine for treatment for depression is considered experimental and investigational (E/I).’ Since then, all of our IOP claims have been sent to Aetna’s investigator for review. We have not received a single claim back. Not one. We haven’t been paid from Aetna for I.O.P. since November.
“Not only did we stop doing ketamine-assisted psychotherapy prior to this notice (mostly because Spravato was becoming easier to get insurance to cover, and we opt to use F.D.A. approved treatments whenever we can; it is only recently that Spravato became covered by most of the major insurance companies despite F.D.A. approval), but it’s very unusual for an insurance company to dictate the medication that is prescribed in an I.O.P. setting. In fact, I’ve never seen it happen, and I’ve certainly never seen a P.P.R. initiated for using a medication off-label. 50% of medications in the United States are off-label and thus ‘experimental and investigational,’ but they [have] no issues being ordered in an inpatient or outpatient facility setting.
“This P.P.R. has been frustrating. Our investigator is difficult to get ahold of. She responds with generic messages that the claims and records have been received, but they need time to review them. She asks that we wait for the E.O.B.’s to fix any errors, should there be any errors. However, we haven’t received any E.O.B.’s, because everything has been stuck at Aetna waiting to process. We haven’t heard from her since January.”
A third insurer, Optum, also put Bespoke on a review. “Bespoke Treatment’s affiliated medical group began receiving notices from Optum in around the summer of 2024 from the Payment Network Integrity department. Instead of putting the whole group on an official P.P.R., we would receive a P.P.R. notice for almost every individual claim that was submitted to Optum. Many were routine psychiatric evaluations and psychiatric follow-ups, but most were probably Spravato monitoring appointments.
“While some of these claims have paid, they have successfully delayed payment for an extra 1-2 months with claim-specific P.P.R.’s. This has been difficult for us to deal with because, unlike Aetna and Anthem, there hasn’t been a formal investigator assigned to us; it’s all done through an electronic portal. So we submit claims, they are reviewed by someone or something on Optum’s end, and then approved or denied later.
“I’ve requested our compliance percentage multiple times and was told it would be faxed to us, but I haven’t received anything. There is no person to speak to about anything. We don’t know what triggered the issue, and we are seeing that their approvals and denials are extremely inconsistent. In a large number of claims, we are seeing that only the first half of the Spravato monitoring appointment gets approved without rhyme or reason. There is no recourse for us.”
California solo practitioner
One solo therapist from the Western United States wrote to us in October last year: “I’ve recently encountered questionable record requests through both Grow Therapy and Alma, all citing ‘Optum prepayment review’ as justification.”
He wrote 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 wrote back in February:
“I’ve seen a stark shift in referrals since undergoing an Optum review at the end of July. Before that, I received 10–12 United Healthcare referrals monthly; since then, none. Aetna referrals have also disappeared, and while I still get some from Cigna, most are inappropriate for my scope (therapy requests instead of medication management). This isn’t an isolated trend — I’ve seen similar patterns reported by other providers.
“In the end, they won. I’ve decided to take an in-house position with a large corporate, not-for-profit medical system. I’ll be integrated into the primary care department, providing support for patients with urgent psychiatric needs — those who can’t afford to wait weeks or months to see a specialist. While this isn’t the work I’ve been doing, it aligns with my core belief: ensuring access to care for those who need it most.
“Ultimately, big insurance and the system they operate within have made it impossible for me to keep my private practice financially viable. So, I’m closing it. They’ve succeeded in pushing out another independent provider. I entered with the incorrect assumption that this was a fair system that rewarded those who worked hard and put in the effort in years of training. Apparently not. Insurance companies decide who wins and who loses.
“This is the result of a pre-payment review involving nearly 400 notes — each one reviewed without requiring a single addendum. A perfect audit. And the reward? A sharp decline in referrals post-audit.”
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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
