Health Net is an example of a health insurer who said they have witnessed a large number of fraud in drug rehab centers.
Many behavioral health professionals say they have such a hard time getting paid that they run cash-only practices and refuse to participate in health plan provider networks.
Consultants from Milliman, an actuarial consulting firm, argued in 2017 that patient use of out-of-network providers is a good indicator of the adequacy of reimbursement for the health plan.
Consultants reported that patients with preferred provider organization coverage were between 2.8 times and 4.2 times more likely to use out-of-network providers than users of other types of care. .
James alleges in his complaint that Optum Behavioral Health has treated behavioral health care providers differently from other providers in two ways.
One was that the organization reduced the amount of reimbursement allowed for services provided by non-physicians, even though non-physicians provide the majority of behavioral health care. The organization reduced the authorized amount by 25% for services provided by psychologists with doctorates and 35% for services provided by therapists with masters degrees, according to James.
Optum has only applied these types of reimbursement rate reductions for medical treatments in limited circumstances, James says.
James says Optum has also treated behavioral health care providers differently by using a special usage review program, the Algorithms for Effective Reporting and Treatment (ALERT) program, on Behavioral Health Care and no other. form of care.
Until June 3, 2019, the ALERT program led Optum Behavioral Health to reject numerous patient behavioral health claims, based on claims that the level of care requested was not medically necessary,
For some other types of care, UnitedHealth used an outlier management program that was much less likely to result in denial of claims, and for other types of care, the company did not use any outlier management method. comparable use review, according to James.
Department of Labor building in Washington. (Photo: Mike Scarcella / ALM)