Optum Is the worst (out of network, no NPI)

[jamiee]

I am sick of dealing with Optum. I had to pay out of pocket for mental health therapy related to a major health issue with a family member. So total is about $2000 out of pocket (just for this), plus other bills. I have a "gold-plated" health insurance plan, so I should get 70% back after my $300 deductible. I'm not quite sure how that works, but I take it to mean I pay 30% and they pay 70% after deductible (they owe me 70%).

Such a pain. My provider has no NPI number. I don't know why they don't have an NPI number and it seems foolish. I am asked to fax in the provider W-9 form. Oh, we can't just take the W-9 form, you need to mail or fax the claims in. Well, it took me 3 months until someone told me to send in the paper forms - the electronic claims have been open for awhile. So I re-do all the NCC-1500 (?) forms. It's 2 "codes" per date of service, so 18 therapy sessions breaks down to 36 lines on the claim form, which is 6 claim forms. Have my family member sign all of those (back from college on break right now). Fax them in last week, was told by one of the reps to follow-up 3-4 days after a fax to ensure they are processing.

Call and get thru to representative #1. She cannot see anything. Over the phone she says their system is glitched, she doesn't see my family member. Says "Oh, I need to create an account for them it will be another 7 to 10 days". WHAT! I've been calling multiple times a month Nearly ballistic, she puts me on hold, but eventually I get disconnected.

I call back to Representative #2. She actually is able to see that the faxes were received a week ago and my claims are "processing". I guess I wait another 21 to 30 days until they tell me what is wrong with the claim again.

I swear that I am an insane, rational human being. I'm just trying to get reimbursed. I already know that they will complain because the mental/behavioral health therapist is a music therapist and I'm going to have to explain that "music therapy is cognitive behavioral therapy." and she is licensed in the state of CA.

Thanks for providing a place to vent... I hate our American medical system.

 

[cyclone_105]

@jamiee

My provider has no NPI number.

Uh - WHAT?!

Your provider is actively violating CMS guidance. (Edit: Note - this is assuming that they do ANY electronic records or billing transmissions - if they don't deal with insurance or e-billing/invoicing at all, it's possible that they don't - but they'd be in the EXTREME minority.) As a HIPAA-covered entity, they've been required to get an NPI for YEARS. This is likely the root of the problem - they're in violation of current CMS guidance which means Optum is kind of in a tough spot as their claims processing system requires an NPI - services have to be received from a qualified provider and per CMS guidance, all qualified providers are to have NPIs. Without an NPI, the claims system is going to freak out. While they technically can process these still, essentially treating the provider as a Foreign provider who wouldn't have a TIN or NPI, I very much doubt that Optum Behavioral Health claims processing guidelines would permit that.

I'm not a UHG/Optum employee, but my company uses them for a number of services, including behavioral health, and we ran into a similar thing where a provider had no NPI (though they also had no TIN as they were essentially acting as unlicensed/unqualified HHC which was found out later when the claim was submitted) - the claim was denied initially and the only way we could get it paid was by pushing a full benefit exception; however, the member was advised that no future claims from that provider would be paid. If it gets paid at all, that's likely going to be their standard as well.

A W-9 form is only to get the Tax ID number for the provider so that they can properly document things for tax and reimbursement purposes.

The CMS/NCC/NIAC-1500 form is a standard claims form - if your provider isn't submitting claims, there's not much that Optum can do until they receive all the required claims information.

I strongly suspect that part of the issue may be that you're reaching out to the Medical side of your benefits when you're hearing that they can't find your claim information; or it had not yet loaded into the system as claims will not appear until they're either in processing or have had a coverage determination made. Medical benefits and Mental/Behavioral Health benefits are segmented at Optum/UHG - on the back of your card, there should be a contact number for Optum Behavioral Health - that group will have all your claims information.

Really though, I would strongly suggest finding a new therapist. If they're not following the bog-standard CMS guidance as a HIPAA covered entity, I'd be concerned about what other operational practices (such as safe handling of your PHI) they're using.

However, to assuage some fear - as long as they're able to get a claim on file with whatever info available, CMBT is a common service and I wouldn't anticipate any issues getting it covered as long as they can confirm the provider's licensing.

Seriously though, I'd find a new provider. A provider who still doesn't have an NPI is likely inattentive to other things which may negatively impact you, and this is going to continue to be an issue for you as long as you receive services from them.

 

[jamiee]

@cyclone_105 They were a good provider, and I don't believe the have electronic billing / deal with insurance. It's a very small family provider. I'm positive they do not have an NPI number -- they claim that "no one else has had this issue". I suspect most of the other clients just eat the out of pocket cost.

I have been told that not having an NPI number just means I submit the paper claim. I am wondering if there's a benefit to also mailing in the claim (in addition to the fax).

I have verified their license/certification is active and I have a number and Tax ID.

Regarding the 70%, It's not like their session fee was high -- it was pretty low, I just would like to get the benefit of my health benefits. Their fee was less than $100 per hour, so I'm fairly certain that would fall below the allowable.

 

[cyclone_105]

@jamiee As long as they've provided a TIN, UHG can run a transaction for them - they'll essentially create a dummy NPI. Edit: Note, you're likely going to have to pay out-of-pocket and then you'll get reimbursed. Since it sounds like the provider is OON, you may not get reimbursed the full amount or even necessarily the typical contracted amount, but you've been advised of this already I believe.

It's super, super rare for providers to not have NPIs, so that caught me off guard until I thought about it a bit more.

No difference in delivery methods AFAIK. I don't interface directly with their correspondence teams, but it's likely processed by the same group. I'd personally wait 30 days which is their average turnaround time for claims, and if it didn't appear on my portal, call and request verification it was received - if it wasn't, I'd request verification Optum Behavioral Health's mailing address and send it by certified mail.

 

[vladimirsurguy]

@jamiee When the provider is out of network, you will not necessarily be reimbursed 70% of what you paid. You will be reimbursed the lower of 70% of what you paid or 70% of what they deem the allowable charge, which is roughly what they would pay an in-network provider for the same service. It’s rare for what you paid to be less than the allowable.

 

[foreverthankful]

@vladimirsurguy Yeah, that 70% means the plan will cover 70% of what the insurer feels is the allowable amount for that service. With in-network, those providers agree to the allowable amounts as a maximum. Out of network the providers don't have to agree to that and can then balance bill you for whatever insurance doesn't cover.

Ie- lets say the therapist charges $200 per hour. Insurance may say the max allowable is $140. If you've met your deductible, insurance will cover 70% of that $140. You will owe the rest, then the provider, who has not necessarily agreed to the in-network maximums can balance bill you for the other $60 (for the originally $200 total).

Insurance companies typically need an NPI number (National Provider Number) from a provider in order to have them be in-network. If your Music Therapist doesn't have on, they can get one free in about 20 minutes: https://www.musictherapy.org/assets/1/18/NPI_7-11.pdf

from there, the provider can then apply to be in-network with any insurance network they'd like- though, they don't have to--- and they don't have to agree to the Maximum Allowable charges either.

 

[shauna]

@jamiee If you haven’t already, check the NPPES registry to be sure they don’t have an NPI. Just in case you asked the office and they weren’t willing to give it.

https://npiregistry.cms.hhs.gov/search

 

[meliorakos]

@jamiee They just cover 70% of the allowable amount and you pay 30%,

 

[avronne]

@jamiee NPIs are pretty easy to find on Google, it does sound a little sketchy.
Edit-does your insurance offer An EAP program that may cover a portion of mental health services? I would definitely speak with your health plan admin if you continue to have issues, if you are comfortable doing so, or continue to post thru reddit, some of us enjoy a good fight and will guide you as best we can