Hello Doctors, Therapists and Staff,
The following is my review, comments and action steps regarding two abruptly launched directives by United Healthcare[UHC]/Optum and Humana. Make no mistake, this is no unplanned error on their part and smells of future onerous rollouts, but I’ll get to that shortly.
In my last e-newsletter I offered an update of the UHC-owned Change Healthcare ransomware cyber-attack and the difficulties a large percentage of the nation’s providers, including hospitals, were having with financial resources drying up. I won’t go into the un-truths and empty promises spewed by UHC CEO Andrew Witty to Congress this past May, but let’s just chalk these two sudden changes to a UHC/Optum departure from that testimony.
The first directive on this hit parade involves a real attack on the validity of a signed Assignment of Benefits, as well as the rights of providers to seek insurance reimbursement. UHC is denying provider appeals for non-payment unless the patient/policyholder has given their authorization, in writing, specifically what is called an “Appointment of Representative”. This draconian act shows why a solidly written Assignment of Benefits form is so critical when fighting back against such insurer tactics. Centers for Medicare and Medicaid [CMS] actually have a form they created [Form CMS-1696] named Appointment of Representative for Medicare-related cases. You can add a derivation of this form to the stack of forms you already have patients fill out and sign, or at the least you can add the following wording to your existing Assignment of Benefits that I gleaned from the CMS form [this in no way guarantees clear sailing should an appeal be necessary, but unless you already utilize an Appointment of Representative it’s better than not including it!]:
“Appointment of Representative: I appoint the provider or provider office named in this form to act as my representative in connection with my claim(s). I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim, appeal, grievance or request wholly in my stead. I understand that personal medical information related to my request may be disclosed to the representative indicated.”
Upon receiving denials of appeals received from UHC/Optum be careful to read the remark/denial codes used. Although at the time of this writing we’re not sure of the codes they will be using it could be a denial based on no proof of appointment of representative. In such a scenario, you will have to appeal once more, but with a properly executed Assignment of Benefits containing the appropriate Appointment of Representative verbiage. By instituting this in your Assignment of Benefits, should you need to appeal a claim you can include your updated Assignment of Benefits, and be sure to make reference that the Appointment of Representative is contained therein. Read, inspect! If you’re not sure of the reason for the denial of your appeal feel free to send to me and I’ll be happy (well, modestly enthused) to review for you – just be sure to thoroughly sanitize the denial so no patient name or identifying information can be seen.
SideNote***: Watch for a future newsletter of another critical addition to your Assignment of Benefits. This may be the most important addition of anything you could ever include in the AOB, and may be the sole means of fighting improper denials and appeals denials. Watch for it!
The second directive to come out was the sudden announcement from UHC/Optum and Humana that Pre-Authorizations would be required for their Medicare Advantage plans for certain healthcare providers, services, and regions. The Humana requirement will begin August 29th, and the UHC/Optum requirement will begin September 1st. I’m going to address Humana and UHC/Optum separately, but I first want to make a couple things clear.
The first has to do with your documentation – review it! Improve it! Whether or not you get the authorization to treat may well be dependent on the validity and completeness of your documentation. I expect an unusual, if not irrational, amount of denials for treatment authorizations, and the reviewer will pin the “nay” decision on insufficient evidence in documentation for your care to be necessary. Don’t make it easy for them to do so. If you can’t be objective in reviewing your notes ask someone smarter than you that you trust, and who can be brutally honest to say whether your notes are worthy of an Academy Award, or not even good enough to line the cat litter box.
The second has to do with diagnosis codes you assign. Remember to always code to the highest level of specificity! If your examination reveals a possible neurological component then code it with a neurological diagnosis code as the primary! Functional and structural diagnosis codes lay somewhere in the middle, and leave the generic pain and spasm as the last to mention, if present. You should be coding like this in all situations, but just in case it’s slipped your consciousness snap out of it!
UHC/Optum Medicare Advantage plans will be the first insurer we’ll tackle as they are the larger of the two and have more of a widespread effect to providers. You must submit the pre-authorization or Patient Summary Form (PSF) request through the UHC online portal after you perform your initial evaluation and before you can get authorization to begin treatments, so be sure you are signed up to do so at www.uhcprovider.com. The healthcare fields requiring a pre-authorization include multidisciplinary offices, outpatient hospital settings, physical therapy, occupational therapy, speech therapy, and chiropractic services that would be billed with the -AT modifier. If you received notification of this new process then you are definitely in an office or region affected. For all the details of what is entailed in properly completing the UHC/Optum Medicare Advantage pre-authorization process I have included the direct UHC webpage at the end of this newsletter following some final comments.
Humana is the other insurer that has enacted a pre-authorization process, and rather ominously the webpage references Humana Medicare Advantage AND commercial non-PPO patients as the targets of the pre-authorization requirement. With this insurer, the responsibility of receiving, processing and approving the pre-authorization requests is not with them, but with a third-party utilization management company, WholeHealth Networks (WHN). Here, too, you must enroll at WHN’s web portal, www.wholehealthpro.com, in order to submit your pre-authorization request. The healthcare fields and services involved are many, but in particular to the recipients of this newsletter chalk chiropractors, physical therapists, and occupational therapists among the affected. Here, too, I’ll put the direct Humana webpage at the end of this newsletter after my final comments. Make sure all providers and staff review these pages together so you can discuss, and I would suggest printing these pages and maintain them in a protective binder so they can be easily referenced, if needed.
It’s ironic that both these major insurers would roll out pre-authorization requirements almost simultaneously. What is even more ironic is that this is happening at a time when Congress, the White House, and Medicare are all trying to force Medicare replacement plans to cut down on pre-authorization requests and the delays it causes in rendering care to patients in immediate need. These insurers are not just thumbing their nose at the government’s request, but are perhaps hopeful that pro-insurance judges will block such government attempts. They are also hopeful that an anemic or non-existent response from providers and policyholders will be seen as a “no harm – no foul” show to both the courts and Congress. It’s all of our duty to let them know otherwise! We must implore our patients to call UHC/Optum [855-586-3843] and Humana [800-758-5002] and tell them to stop blocking or holding up access to care they need; and then call our state and federal legislators and ask them why they are allowing these insurers to institute onerous pre-authorization protocols when Congress is in the process of trying to get insurers to do just the opposite. If you would like a printable flyer that you can hand out to your UHC/Optum and Humana Medicare patients email me and I’ll send as an attachment.
There are other theories as to why these insurers are enacting these protocols at this time. Some feel this is their way, especially by UHC/Optum, of recouping millions of dollars in losses suffered by the UHC-owned Change Healthcare debacle several months ago. Many providers and hospitals still haven’t been made right financially, and between potential fines and having to pay late interest to providers UHC is trying anything they can to limit their financial losses. Other theories, which I am very leery and suspicious of is that this is a test before launching similar requirements for their other insurance plans. You test the temperature of the water by rolling out your plan to a smaller market to see what the reactions will be. When temperatures cool, or there is little to no repercussion you widen the rollout to include other plans, larger geographic areas, etc. It’s a sinister method that been done successfully many times before.
It’s crucial that we not be complacent and roll over when such challenges fall to us. We must be diligent in pushing back, and it’s just as important that we educate and encourage our patients to do the same as they are paying for better treatment than this by their own insurance company. Make the calls, you and staff; dial the number and hand the phone to patients when they come in. With enough complaining, persistence and fortitude just like Jericho we might be able to bring these walls tumbling down!
UHC/Optum Pre-Auth Webpage
Humana Pre-Auth Webpage
https://provider.humana.com/coverage-claims/prior-authorization
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Yours in health and wealth,
Dr Art
Dr. Arthur I. LeVine
CEO & Founder, iCollect Medical Billing Services, LLC
Past President, Florida Chiropractic Assn.,
Board of Directors, Florida Chiropractic Assn.,
Chairman, Insurance Relations Committee, Florida Chiropractic Assn.,
Co-Chairman, Government Relations Committee, Florida Chiropractic Assn.,
Florida Representative, Congress of Chiropractic State Assns.,
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