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Do Optum’s Changes Mean You Will Lose Clients at Your Treatment Center?
How a notice given by Optum drastically affects client coverage
Recent changes to Optum’s coverage mean that if you are an OON provider, you may no longer qualify to secure payments with them.
Optum recently released a notice titled “Update to member service area coverage for OON benefits” which stated changes that affect OON care, effective July 1, 2021. This directly affects:
· Alternate Care Facilities - PHP or IOP
· Freestanding Facilities - Psychiatric or Substance Use
· Residential Treatment Facilities - Psychiatric or Substance Use
· Inpatient Rehabilitation Facilities - Psychiatric or Substance Use
Why did they do it?
It appears that Optum is giving preference to a smaller number of providers and reducing choice for patients, all while collecting the same fees. This change also appears as a cost-cutting measure for Optum, by reducing instances where they cover the cost of care rather than an employer.
Why not just go to INN?
OON providers experience greater flexibility, can treat a wider range of OON clients, and receive greater reimbursements when doing so. These reimbursements are more closely aligned with the costs of care than those that are received by INN. There is a greater number of insured that are OON and the option is more attractive; it provides them with greater flexibility to pursue high-quality care that suits their needs and offers more convenience- all for higher premiums.
INN members now appear to be given preference by Optum by eliminating the choice for patients to go OON and removing a major component of patient choice in treatment options.
How this affects those with SUD
People suffering from addictions who would have sought care away from their typical surroundings and triggers now no longer qualify to get treatment out of their service area.
Areas of confusion
The notice has left many providers and clients with questions. For instance, what constitutes a service area is still vague. Whether this means city or state boundaries is unclear. For patients who live in more remote areas, this drastically reduces their chances of receiving adequate care.
Even more concerning is that the notice advises INN facilities to prepare for an influx of patients once the changes take place. This implies that the changes will have a direct effect on the people already admitted in OON facilities, counterproductive to recovery and standards of care.
OON providers are unsure about what is next. The notice does not address them or provide guidance on the next steps, leaving many providers unsure about their current OON clients and what is to happen once the notice takes effect.
Suggestions provided for OON providers by Nelson Hardimen are:
· Contact Optum as soon as possible to find out if patients currently in treatment will lose coverage;
· Ask Optum if there is a way to appeal the decision on a patient-by-patient basis;
· To avoid non-payment, clarify with Optum before admitting any new “Fully Insured” patients; and
· Notify patients about the potential for having to pay out-of-pocket or transfer.