Therapy Patients Stop Treatment After ‘Pre-Payment Reviews’ Swell
EDITOR’S NOTE:
Below is an excerpt of an important piece originally published in ClearHealthCosts on September 10, 2024, by its founder, Jeanne Pinder.
A number of psychotherapy patients in the Northeast have stopped treatment because their insurer, UnitedHealthcare, is requiring substantial paperwork for what it calls a “pre-payment review” that has stopped reimbursements, therapists say.
The interruption in treatment comes after UnitedHealthcare’s Optum subsidiary began subjecting thousands of payments to a “pre-payment audit” in the last several months, the therapists say. After the visit takes place, the out-of-network psychiatrist or therapist is paid by the patient (usually) and the patient submits the bill for reimbursement, to UnitedHealthcare. But Optum, the subsidiary managing health services 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. (View ClearHealthCosts’ earlier post here.)
“The impact of these reviews is raising concerns about delays in treatment (since many pts are holding off on additional sessions out of fear that the treatment will not be covered), patient privacy, delays in reimbursement, and unnecessary additional administrative burdens on psychologists,” wrote Dr. Jax Gallios, an out-of-network psychologist in New Jersey who submits bills to United on behalf of some of her patients. “It is also raising parity concerns, including further constriction of the already difficult access to mental health care through insurance.”
Gallios said “people STILL haven’t heard back after submitting records for the massive influx of pre-payment review requests — they have up to 45 days to respond to providers after documents have been mailed. I personally haven’t heard either.”
‘Very destructive’
June Feder, a psychologist practicing in Manhattan who is chair of the New York State Psychological Association insurance committee, said others are stopping too.
“Some have notified psychologists they cannot continue treatment because they are not getting reimbursements,” she said in a phone interview. “It’s very destructive.”
A Connecticut psychologist who spoke on condition of anonymity said she also has a patient who is pausing treatment, though she told the patient “I don’t think it’s best” to stop.
It’s not only patients cutting back, but also clinicians.
A West Coast therapist wrote: “I’ve had to reduce my schedule to 60% capacity” to meet the administrative burden. He said he had received dozens of record requests, followed by dozens of duplicate requests.
“Each new request takes 55 minutes to process, and each duplicate 22.5 minutes,” he wrote.
Reports are anecdotal so it’s hard to say how many patients and therapists have quit or cut back. But if patients who paid for services expecting insurance reimbursement are not getting paid (at least one has not been paid since May) and clinicians submitting bills and expecting payment are not getting paid, then it is easy to see how things might shut down.
Other billing challenges
For patients and clinicians, the context of the payment delays also matters. “The thing that I want to underline is that this is coming on the heels of what has been a very difficult period,” said Dr. Marnie Shanbhag, a Florida licensed psychologist who is the American Psychological Association’s senior director of the office of independent practice. “We have not seen demand for mental health services let up since the pandemic, when the demand really did soar. I think we we all understand that people were very stressed out during that period and and are still coping with the fallout.”
The payment delays are particularly damaging to therapists because of the timing, Shanbhag said.
At the turn of the year, many practices encountered delayed payments because of an update in medical coding practices for Medicare, she said. Once the systems were updated and payments began flowing again, the massive Change Healthcare data breach took place, and payments stopped again. And now these pre-payment delays are further stressing psychology practices.
“Providers are really feeling like they’re at the end of the proverbial road in dealing with just one thing after another, all of which seems to delay payment,” she said. “Much of mental health care in this country is provided through small, individually owned or small-group independent practices, so they don’t always have large resources and reserve funding that maybe hospital systems, etc. might have.”
The pre-payment reviews were seen before the pandemic, Shanbhag said. They were not that common for a while, she said, but then recently the A.P.A. started hearing large numbers of pre-payment reviews, currently primarily centered in New York, New Jersey and Maryland. It seems to be affecting out-of-network psychologists more than in-network, but both are affected, she said.
‘Unnecessary burdens’
“It’s particularly frustrating because nobody wants to engage in unnecessary administrative burdens,” she said. “When you are out of network, you’ve essentially chosen not to participate in an insurance system for all kinds of reasons. One might be, you don’t want to engage in this kind of administrative work that is overwhelmingly uncompensated.
“So it really puts you in this very difficult position vis-a-vis your patient and the insurance company. Here’s an insurance company that you have not contracted with, and you’ve often been paid by your patient, but in order for your patient to recover some partial reimbursement from the insurance company, they are being asked to have the provider do this. And we don’t want to create additional burdens for our patients. A company that you are not contracted with is now requiring you to do things. If you say no, you’re worried you’re going to hurt your patient.”
Another issue is the insurance companies’ specific demands, she said.
“We are not privy to the documentation requirements for these insurance companies because we are not contracted with them,” she said. “So they may choose to flag certain records or deny certain record claims because of inadequate documentation, but we are not educated about those documentation requirements because we’re not on contract.
“Often the things that they flag seem to be incredibly minor things that don’t actually affect quality of treatment provided. For example, insurance companies love to make sure that records have start and stop times. We will often say in the record ’45 minute session.’ But really what they want to know is that the session, let’s say it was a 2 P.M. session. It actually started at 2:04 and it ended at 2:49, and you can imagine the kind of minutia record-keeping that would require, in a day that you’re seeing back-to-back patients. And the start and stop time really doesn’t affect the quality of the care.
“Also, let’s say I signed the record ‘Marnie Shanbhag,’ but I didn’t say ‘Marnie Shanbhag, licensed psychologist’ in my signature, even though the note itself is on an office form that says ‘Dr. Marnie Shanbhag, licensed psychologist’ with with my license number on that form. It isn’t even that the page is missing that information. It’s just that they wanted the handwriting of the signature to include that information. Again, not something that we would say affects the quality of care.”
Also, she said, an out-of-network psychologist has great difficulty in calling an insurance company to explain or reason with someone. If you’re out of network, the phone tree doesn’t work. “It’s a tremendous barrier,” she said.
She said the A.P.A.is collecting information about the scope of the payment delays, and after that will determine a course of action.
Will the A.P.A. have a response as a group? “Normally in those kind of situations, A.P.A. would not have an official policy on a concept like a prepayment review, because our practices are all individually owned by by psychologists,” she said. “They’re not owned by us, and the contractual relationships between the insurance companies and the practices are really outside of our purview. But we certainly try to contact insurance companies and do what we can to understand the issues and to help members navigate.”
“Historically, what I can say is that when we reach out to insurance companies, generally speaking, we often end up with more questions than answers. Many times they’ll want a list of providers and patients to begin that process. So you can understand that for our providers, it’s a very anxiety-provoking issue, and and they don’t always want to be identified, given that they worry feeling targeted in these kind of situations.”
UnitedHealthcare response
We sent these questions to UnitedHealthcare, asking about patients stopping treatment, but got no response. We will update if they answer.
“1. Was this result envisioned under the pre-payment review policy?
“2. Do you have advice for patients or therapists who are seeing this happening in real time and expecting possibly dire consequences? The therapists we have spoken with say they are complying with these often onerous records requests, but payments are still not being made.
“3. Is this a violation of the Mental Health Parity and Addiction Equity Act?
“4. How many therapists and patients are in the pre-payment review process now?”
The Optum letter to clinicians about the pre-payment review 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.”
Items listed include “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.”
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Its all by design; systematically delaying payment for rendered services is essentially denying care. Small practices can't afford to stay in business in this restrictive environment and that's another goal insurers have: consolidation and avoiding leakage outside their system. It's a big reason why I stopped practicing in 2018 and has only gotten worse. Instead of making joining networks more appealing and advantageous for clinicians, they're trying to force out of network clinicians to play their monopoly games. It's disgusting to watch how they continuously hurt both patients and clinicians while pretending they've done nothing wrong. It's operational narcissism. These people need to go to jail.
In 2023 the plan hired new VP’s for clinical review. These persons were tasked with coming up with a strategic plan to make the UR process profitable. And they did. They are squeezing the lemon as it was put to staff.