In August, APA Services, Inc. began hearing numerous complaints about prepayment reviews (PPRs) conducted by Optum, which is part of United Healthcare and manages behavioral health for that insurer. Without warning or explanation, Optum had sent psychologists letters telling them that claims they submitted (or that patients submitted) would not be paid until the psychologist faxed or mailed Optum extensive patient records. Optum said they would then take up to nine weeks to review those records and decide whether to pay the claims. 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.
APA Services coordinated advocacy with the American Psychiatric Association, especially on the joint letter to Optum (PDF, 140KB)opens in new window. 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, APA Services met with Optum to discuss those concerns, as well as psychologists’ complaints about claim denials. Optum acknowledged those concerns and informed APA Services that it had paused the PPRs of psychologists. (APA 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 APA Services so that psychologists are aware of the company’s documentation expectations well in advance of further reviews. APA Services urged that any future reviews should be nothing like the confusion and disruption of the recent PPRs.
APA Services is pleased that Optum claims to have ceased the highly problematic PPRs for now but remains concerned about the reported exceptions noted above. APA 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.
