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.
It goes like this: The visit takes place, the out-of-network psychiatrist or therapist is paid by the patient (usually) and the patient submits the bill for reimbursem*nt, to UnitedHealthcare. But Optum, the subsidiary managing health services and technology for UnitedHealthcare, sends a letter to clinician and patient saying it wants detailed records for a “pre-payment review” before sending money. No reason is given.
Most reports at this point seem to be out-of-network, with patients paying and then seeking reimbursem*nt as per usual, but finding themselves in limbo — but there are some reports of in-network clams in the same limbo, and one of a psychologist who submits for reimbursem*nt for her patients and got the same letter. Most of the reports were from the New York City area.
“There’s been a lot of buzz on professional mental health clinician listservs about a flurry of record audits, including out of network audits,” Lynn Spevack, a New York psychotherapist and practice-building consultant, wrote in an email. “While audits aren’t anything new, my impression is that there’s a big increase, perhaps particularly through Optum (which, I believe, is on behalf of United Healthcare).”
As she said, pre-payment audits are not entirely new in healthcare. It’s long been an issue: Sometimes an in-network procedure gets pre-authorized, and then there’s a pre-payment review. What’s new is the surge in numbers — anecdotally, to be sure, but still noticeable, and especially in mental health.
‘New, predatory and obstructionist’
“The Optum letter uses the language ‘pre-paymentreview,'” Dawn Baird, a clinical psychologist in Rye, N.Y., wrote in several emails. “I received two such audits from Optum as an out-of network provider during the past two months.In the more than 20 years I have been in private practice in psychology I have NEVER received such a request. They requested the ENTIRE medical mental health record (encounter, progress notes, treatment plans and goals, claims, bills, referrals, invoices, signature and credentials verification [whatever that might mean- ] as well as a reference key for any non-standard abbreviations.
“Even with an electronic medical record keeping system (which many clinicians do not have as they are costly), this represents hours of work for clinicians (and therefore takes away from client care). One client is a minor, and the amounts vary between $3500-$5000 Optum says they need to verify if the claim is accurate, but I know that they have already received invoices from the client which were marked paid, and this amount of data requested is well beyond the scope of verifying that sessions occurred. Furthermore, they have withheld any payment to the clients prior to this ‘audit’ / review.
“My client was told by the insurer that these reviews slowed down during COVID and now are ‘picking up,’ …This form of review is new, predatory and profoundly obstructionist in the context of an ongoing mental health crisis. Must we all wait for class action lawsuits such as with Multiplan for some greater insurer accountability or perhaps some semblance of parity for mental health care?
“The insurance letter included a deadline of 45 days with a date beginning in January for these documents,and I received theletter more than 20 daysafter it was allegedly mailed. Previously, when any records are requested (generally for a review and not a preview), a treatment summary is acceptable to verify sessions past or need for treatment going forward (also highly problematic), however, Optum is saying this is insufficient. It is particularly outraging because very few of my clients receive ANY monetary benefits given the extremely high deductibles among most current plans.
“From where I stand, far too few people are able to access the mental health care that they need because they are paying virtually entirely out of pocket to begin with (as most people do not meet their deductibles on standard plans). The lack of access to mental health care (even among middle to upper- middle class) means that far too few people are receiving close to the mental health care they (or family members) need because of obstacles in the form of fees & time, etc- even among ‘monied’ people. This lack of access to care costs us all as a society in the long term, and we are seeing the terrible impact of this in the form of increased rates of suicide, violence and addiction. Our mental health as a country is at an all time low (in my lifetime), and it is nothing short of disturbing that insurers are implementing greater hurdles for patients and providers alike while their own profits increase.”
She pointed out that the demand was for “entire mental health records in light of sensitivity of content and data breaches.” Change Healthcare, part of Optum, had an enormous data breach earlier this year.
Baird is out of network and has never accepted insurance.
A therapist on one listserve sent this snippet from another member: “I don’t have much information but this is a widespread problem. I understandNYSPA [New York State Psychological Association]is in contact with APA [American Psychological Association] and there was supposed to be a meeting today with the NYS attorney general’s office. Psychologists who are members ofnyspaare encouraged to write to Nyspa@nyspa.orgto add their voices.“
NYSPA promised to make someone available for comment but we did not hear back. We will update if we hear from them.
(Update, Aug. 23) Optum acknowledged a request for comment but did not respond. After this posted, the Optum media person sent a note saying: “Hi Jeanne, I noticed that your story published this morning and hope you’ll update with our statement below as indicated. Thank you. ‘Optum continually works with and incorporates provider feedback to enhance our review process and improve efficiencies, including recently creating a digital portal for providers to submit records. Our process is in place to ensure members have access to quality care that is consistent with their health plan and our reimbursem*nt policies.‘” She asked that it be attributed to Optum.
We did not speak with any patients.
‘Interfering with patient care’
A psychiatrist in private practice and on faculty at several prestigious New York institutions, who spoke on condition that his name not be used, called the practice “United & Optum’s strategic pattern of interfering with patient care.”
As an M.D., he treats patients with a combination of therapy and medications. “What happened to me turns out to be happening to a lot of colleagues,” he said in a phone interview. “They started requesting records with no reason or anything.
“I bill the patient, then they submit to the insurance company. But the insurance company will not pay the patient until they get records. They won’t say what the records are for, but patients are not getting reimbursed.
“It introduces a level of uncertainty and anxiety. Patients get more anxious and more depressed. It’s unclear if they can continue their treatments, or what else they will have to cut back on if they want to continue.
“The tactic is to delay and deny — introduce a new element of what information is going to be necessary for the patient to give to the insurance company. A patient is concerned — ‘Will they know I smoke pot?’
“If the patient is getting better, United has said ‘then stop the treatment to see what happens.’ If they’re not getting better, ‘it’s not doing any good, so change the treatment.’ They want to manage medications — change the dose, or if you haven’t, try a different one. And then they begin to deny treatment.”
No payment without records
He said this had happened to one patient, who had reached the point where “after X amount, insurance will pay 100 percent” but then Optum told the patient and psychiatrist there would be no payment without extensive records. “The patient doesn’t know if treatment is going to be accessible,” he said. His patient asked him to send records, and he will, he said.
“My patient has not been reimbursed for May. So it’s been two and a half months,” he said but for colleagues it has been longer.
“When this happened to me, I thought it was just a one-off,” he said. “But I’ve been in social situations, professional situations, religious services, where people in the mental health field are all ‘Hey, did you hear from Optum, UnitedHealthcare, wanting records?’ People are talking about how it’s affecting patients.”
Another level, he said is “what is your job in terms of advocacy? At what point are you abandoning them if you don’t fight hard enough?” At the same time, he said, clinicians don’t want the insurance company to retaliate against them. And there are privacy issues: He is not under contract with United, so he does not want to send them patient records with no guarantee that they will be kept private, especially in light of recent data breaches. He has asked his patient for a release, but that also seems problematic.
No recourse
“The patient’s concerns are ‘I can’t keep going with this,'” he said. “But Optum-United Healthcare do seem to have a systematic strategy to minimize, obviously their cost and maximize the patients’, and decrease their access to services. Or they don’t care if they use services or not, they don’t want to pay for it.
“There are very clear clinical consequences, and there is no recourse. The appeals process is very long and people get discouraged and exhausted. During an appeal, there is a level of uncertainty. And these are people who are vulnerable.”
When did this process start? A few months ago. Is it all insurers? No, only Optum-UnitedHealthcare.
What reasons are cited? “There is no reason cited. One of my colleagues tried to clarify that. My patient says the reason is clear. It’s because they reached a maximum after which United or Optum was supposed to be paying the whole thing.”
The patient is 23 or 24, he said, having weekly psychotherapy and some medicine for a combination of ADD and depression. “This is a fragile time in his life. Given the epidemic of mental health crises in that age group, you would think that this an insurance company would be more tuned into that. But I guess that’s not the way business works.”
For some colleagues, he said, “They are just looking to see that the billing codes match the notes. And for some of my colleagues everything still seems to be pending. Months later, there doesn’t seem to be a resolution.”
Some colleagues have been asked for additional records because of what Optum calls “aberrant billing,” he said, with no explanation. Psychiatrists who do therapy also generally split each session into two codes — the medical billing code, for medication, and psychotherapy code. Psychologists and social workers just do the psychotherapy codes, he said.
Aggression, depression
“It creates this new way of thinking what is our role? Of course, if we take on the role of advocate, which many of us do, outside of a purely dynamic situation, we do want our patients to be reimbursed. But once you take on the role of advocate, it’s also a lot of unreimbursed time.”
Then, he said, if patients aren’t getting paid, “Are they going to direct aggression or depression against themselves, or against the provider? Because directing it against the health insurance company, which everyone does, feels really, really helpless. My colleagues and I don’t want more retaliation.
“The patients say, ‘you know, I can’t really push back that hard. What happens if I then end up with an emergency or a major medical illness’ — which some have already — and then they stop paying for this or that? The idea of retaliation from the insurer — while it would be great to just consider it as a neurotic situation — is very real for a lot of people.”
“When it comes to insurance companies, the capriciousness and the relentless pursuit to delay and avoid payment really creates a sense of, they’re being attacked and pursued. Is this something we just accept as a condition of modern life?”
Dr. Jax Gallios, an out-of-network psychologist in New Jersey who submits bills to United on behalf of her patients (most out-of-network psychologists are paid by the patient and then they provide a superbill and the patient chases reimbursem*nt) said she submitted claims to United in June for the only two patients she has who have UnitedHealthcare insurance. All those claims were put into review.
“No reason” was given, she wrote in an email.“These are the only two patients I have that have the insurance UHC/Optum that I submitted June claims for. If I had others, I would have no doubt they too would have been subjected to the pre-payment review.”
‘All medical records’
The Optum letter says, “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.”
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.”
The items listed:
“Office visits: All available documentation for the services rendered, including but not limited to: 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.
“Initial inpatient or hospital request: Emergency room records, admission records (initial patient intake form, face sheet, nursing assessment, inpatient physician order, initial intake visit, etc.), discharge summary.
“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.”
“The claim is on hold until records are received,” the letter says, saying a review will begin that could take 30-45 business days. If the claim is supported, it will be processed; “if the requested medical records are not received by the deadline, the claim will be denied.”
“The prepayment review requirement for your claims will end once we determine that the medical records consistently represent the services billed.
“Questions? We’re here to help.”
The letter is signed “Sincerely, The Pre-payment Optum Program and Network Integrity Team.” The letter is sent to the clinician, with a note that a copy is sent to the member.
‘Very, very dangerous’
A clinical psychologist in New York City who has been in private practice for 32 years and is out of network said it had never occurred to her as an out-of-network clinician that she would have trouble with an insurance company. But she recently got three requests from Optum for pre-payment review, two for the same patient and one for a different one. She spoke in a phone interview on condition that her name not be used.
“In the past, when an insurance company needed to know something, they would ask you to write up a summary and include various things like a diagnosis. But they would never ask for your process notes.
“This is very, very dangerous. I have two patients with the same diagnosis, generalized anxiety disorder. It’s a milder thing, and I would think that’s one of the red flags. Also one patient I am seeing more than once a week.
“One of my patients is in a terrible custody battle that has gone on for 3-1/2 years with a sociopathic spouse, who really has no interest in the child but wants the money. I have to be very careful of what I write, the diagnosis I give. I cannot do anything that puts my patient in danger.
“Anything I say that goes to a third party can be gotten by this sociopathic spouse and used against the patient. My requirement is to take care of my patient’s needs, not to satisfy the insurance company’s desire to prove that I’m actually talking to this person each week, and what are we talking about?”
Call center in the Philippines
She said she called the help number on the letter, and it was a call center in the Philippines. The woman on the other end said the therapist has to put the start time and stop time of the session on every bill — simply using the CPT code 90834, which indicates a 45-minute session, is not enough.
“I have to write these idiotic symptom descriptions and subjective reports and interventions used,” she said. “The thing called interventions used, they have to be ridiculous, things like ‘active listening,’ ‘communication skills training.’ This whole group of things that an AI will accept. It’s nonsensical. This isn’t how people work. People work by making a relationship with the person and doing what’s needed for that individual person at that exact individual moment.”
“For the month of June, I have two patients, and I have to do these audits, which are taking me so much time, because there’s so much information that I’m learning they want,” she said. “For each record, instead of just putting the information and then the date, then how much it was, and you sign your name, and then they pay the patient. They’re asking for you to put on every single note, the date, the patient’s name, their ID number, the CPT code, which is the 45-minute session, the start time, the end time, then my name. Also, I’m a Ph.D, but I was told by the woman on the call service that I also have to put the word psychologist. And then you have to put license number, which is on my bill. If not, they will fail me.
“And they also want patient progress response for each and every session, the patient progress in that session. They stop having a panic attack? They’re not crying anymore? Or they understood something they never understood before, about why they felt so traumatized by x event? That’s not gonna pass.
Designed to end therapy
“And then and you have to have a treatment plan for the patient so like you’re supposed to say, I don’t know — my patient will not be anxious anymore. And the thing about it that looks so offensive is it’s not designed to be helpful or to make sure that something is happening that’s proper or right. It is designed to say that the patient does not require therapy and they will not pay for it.
“They can keep pre-auditing you. They can do it every month, with all this information going to this third party, who can be hacked at any time. Think about the things people tell people in therapy, all the sexual stuff that people talk about. Think about the fact that people go through manic periods when when they’re bipolar, and you help them, and you get them back on track, and they go to work, and nobody knows the better for it. It just makes me want to cry, because this is what I do, with my whole heart and soul, to help people. And then I have this company coming in and demanding things they have no right to demand and putting my patients in danger.”
How are her patients reacting? “It just puts them in such dangerous positions. This kind of information should not be anywhere but with me. That’s why we go to a psychologist, who has a requirement to protect their information. Think about how hard it is for someone to come to you, a therapist, and talk about what’s painful and upsetting to them. Think about how much trust they put into you. And they’re supposed to be covered by an insurance, but instead, they’re put at risk. And emotionally, the thing that’s supposed to be so private is no longer private.”
She said it was not clear what triggered the review. One patient comes twice a week, she said, and speculated that United may not have liked that. Both were patients she sees remotely.
She said a longtime therapist she knows who got a similar review letter told her she was not going to continue practicing — saying “it’s not worth it to me anymore. I can’t put myself through this.”
‘Our purpose was to deny’
On a Reddit forum about the topic of reviews from two years ago, one poster wrote that one trigger is the medical code used: “Hi there! Optum worker here! Basically we have this thing called the ‘KL’ and it tells us the frequency all codes should be used, per Optum standards. [CPT code 90837] can only be used twice per day, 60 minutes each. Someone on the thread said that our purpose was to deny payment — and that is completely true! Here in the claims department, we need to process 175 to 200 claims per day at a pay of roughly 10.75 per hour. We only get 1-2 minutes with each claim, and management has instructed us to trust how the system is set up. So if they have you set up to deny all your claims, we must comply.”
On another Reddit forum, a month ago, a poster who is clearly a patient wrote: “Are Optum’s business practices regarding behavioral health fraudulent? I have now had two claims for behavioral health placed on hold because Optum wants ‘medical records’ from my provider. I have already appealed the first one because they denied it after my doctor submitted all he had (a 20 page report on the testing he performed and diagnosis.) Now I received another ‘records request’ for therapy sessions. I’m starting to see that they just do this for all claims in hopes people just don’t respond. I’ve never used my out of network benefits and cannot believe the hoops I have to go through to get what I’m owed under the policy. I see some posts on Reddit about this practice. Is this a known issue in the industry — that Optum denies behavioral health claims under the auspices of needing more ‘medical records’?”
On another Reddit forum, a poster wrote: “Wondering if anyone has experienced UHC/Optum requesting medical records to complete a pre-payment review for claims that a client submitted OON to them and how you handled it. This seems incredibly invasive, especially given that I am not a contracted provider with them. Thanks!”
In and out of network
A licensed psychologist in private practice from upstate New York wrote, on condition of anonymity, in an email: “Although I have not had a pre-payment audit request from an insurance company personally, one company in my area informed all its providers (not just mental health providers) that these audits will be starting to occur. This particular company has given specific information about what they are checking for and why the audit is needed, with payment being delayed until the company has had a chance to review requested treatment records.
“This specific information stands in stark contrast to what I am hearing from colleagues in another area of the state who are being audited by the OptumHealth company. Apparently, prior to paying certain claims, Optum is asking for all records and billing to be sent, and is not stating what they are looking for in order to approve payment for the audited sessions. They are auditing both in-network and out-of-network psychologists, and have 45 days to complete the audit.”
“This audit is delaying payments for the in-network therapists, and delaying payment to the patient who sees an out-of-network therapist. While it is burdensome for a psychologist provider to have payment delayed or denied pending further audits, it must be especially burdensome for a patient who believes they will be reimbursed to learn about the pre-payment audit process delaying or denying a reimbursem*nt they have been getting previously from their insurance company.”
Sent to old address
Dr. Lauren Jessell, director of a group practice based in New York City, said she had receivedthree requests for records sent in July 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.
Like the others, she said she doesn’t know why these particular claims were chosen. Like the others, she got a request for all medical records related to the claim – progress notes, treatment plan and goals, and any other documentation would fall into that basket.
She tried to inquire by phone, but felt the rep she spoke with was “literally reading off a script” and she didn’t get much useful information.
She says the letters were sent to her old business address and she may not have received them had clients not also informed her. Shenoted “the letters say I have to send them in time for Optum to get them within 45 days of the date on the letter. I saw copies of the letters from Optum that clients received, it was just a copy of the letter sent to me and one line telling them no action was needed from them but clearly action had been.”
‘The ability not to pay’
Dr. Owen Scott Muir, a New York City psychiatrist who writes about healthcare atThe Frontier Psychiatrists, wrote: “This is a magical way of getting rid of prior authorization while keeping the ability to not pay when it’s the most profitable.
“The whole business model of health insurance companies is to control the money they spend. It’s not to spend less! It to spend just enough more each year, such that it matches the Medical Loss Ratio. That number, which is the basis of a congressional law, says they’re allowed to make only a certain percentage of the total money they bring in as profits. So if they bill $1 billion in premiums, the most profitable outcome is to spend 80% of that on expenses, paying for drugs, paying for doctors. And then they raise the premiums the next year, and then they get to keep 20% of even more as profits.”
Scott Haas, a vice-president at USI Insurance Services, a brokerage and consulting firm, wrote about pre-payment audits on a listserve: “Patients have a right to know what services will be provided and at what cost in advance of the procedure. This whole business of second-guessing clinic necessity and what is payable after the fact harms patients and providers and adds no value to the transactions.”
The American Academy of Family Physicians (AAFP) has also taken note of the practice, in a non-mental health environment, where a physician’s practice might be compared to the practices of another. In a statement, it said it “believes indiscriminate use of pre-payment and post-payment audits is a significant business disruption and administrative burden for the physician office and creates an inappropriate culture of mistrust. Many audits are promulgated by health plans that compare physicians to peers.
“The notion a primary care physician’s billing practices can be adequately ‘compared’ to those of their peers presumes patient panels are similar and all nuances of a patient visit can be accounted for during the visit. However, patient panels can vary due to multiple factors, including, but not limited to, geographic region, age, sex, income, education level, physical environment, mental health, etc. Further, the complexity of care, scope, and breadth of care involved in primary care visits is difficult to measure, much less compare across physicians.”
Experity, a company with business and technology services for urgent care clinics, also wrote about the practice. “Pre-payment reviews occur when your practice’s claim data is analyzed by the payer and a provider has been identified as an outlier. For example, Dr. Jones is billing more level 4’s than other providers of the same specialty in your area. Practices are notified by letter stating which provider and which codes will require a review prior to adjudication of the claim with the date the pre-payment review takes effect. Claims for the provider with codes under review require the medical record be included at the time of initial claim submission. Failure to submit the medical records will result in a claim denial and further delay in payment.”
The surge in behavioral health audits also raised a question: Is this surge also happening on the non-mental health or medical side? If not, then it may be a violation of the Mental Health Parity and Addiction Equity Act, which requires health plans and insurers to treat mental health benefits in parity with medical-surgical benefits.
Making more jobs
One person on a listserve tied this practice to job growth: “Politicians get elected by growing jobs, increasing taxes (not the rate but the dollar amount) and healthcare delivers, every time. Those job earners are the biggest property tax payers (forget the tax free hospitals – just the personal property), the drivers of home purchases, retail sales tax, and so many other economic drivers.
“Healthcare jobs are economic crack – especially in rural America where they may literally be keeping towns alive even as they weaken everyone living in them. Those jobs are killing us.” After he posted, I asked if I could use his name, but he didn’t respond. Good answer, though.
He then inserted a chart on growth of healthcare workers vs doctors, taken from AthenaHealth, titled “Healthcare administrators far outpace physicians in growth.” Athena calls itself an “integrated practice solution,” contracting inside of healthcare to move money around and check business practices.
‘A perfect storm’
Baird, the Rye psychologist, wrote: “For the duration of my career (some 25-30 years since the beginning of my training) I have witnessed a horrifying shrinking of mental health services.Psychiatry has never been the favored child in the world of medicine, but budgets have been slashed and many programs closed in New York and elsewhere.In the absence of hospital care, people turn to outpatient clinics and providers.It is excruciating to be a mental health provider during these times, as it is akin to watching a perfect storm develop.Ever less care with ever greater need. Covid-19 increased demand for mental health care in an unprecedented manner, and many people (in all communities) are faced with a complete lack of available and affordable mental health services. Many clinicians still have wait lists, and unfortunately we have a generation of youth and families in crisis (my colleagues discussed never seeing suicidal 8 year olds prior to covid), while insurers are playing audit games to avoid paying for mental health services.
“This backdrop of desperate need makes the actions of companies like Optum all the more egregious, abusive and exploitative. Similar to the Multiplan scandal, these ‘audits’ are no accident. They are powerful deterrents for patients and clinicians alike, as practitioners are buried in paperwork (thus havefewer hours, deterred from submitting forms by the scope of the task) while patients remain unpaid.In the case of my clients, they are withholding this entire year’s worth of claims. We were told that once a claim is audited, every following bill is subject to the ‘review.’
“Worse, they arepreying on a group of people who are already overwhelmed and often unable to cobble together adequate care at a time of a public mental health crisis. It is a moral outrage, and if business continues as usual there will be a tsunami of mental illness. Far too many people are suffering without proper care.”
What you can do
Barbara Griswold, author of the blog“Navigating the Insurance Maze,”and thebook of the same name, is a therapist who advises other therapists on various aspects of the business of a practice, especially insurance.She wrote in a newsletter about the surge in pre-payment reviews, and added a list of “What should you do if you get one of these requests?”
“Ask the client whether they want the records released.The records are theirs, and it is their right to decide whether to release them or to block the release.
“If they choose NOT to authorize the release of their records,be sure they understand that this likely will mean that the plan will NOT reimburse them for the sessions. The client will have a period of time to turn over the notes, and the claim will be closed if these are not provided.
“If the client DOES authorize you to hand over your session notes,have the client sign a written release.You’ll need it before you send anything or even speak to the health plan if you have a question.
“But what should your release say?It should allow the release and exchange between therapist and health plan for “any information necessary to process claims or superbills, including but not limited to the release of session notes, diagnoses, test results, and treatment plans.”
“Since you are getting a release for notes, I suggest you adda phrase that covers the possibility of a telephone treatment review with the plan. Something like“I also authorize my therapist to release information to the health plan for a telephonic treatment review, if requested by the plan.”
