Optum Announced Restrictions for Certain Plans. What Does This Mean For You?

Optum recently announced that it will restrict out-of-network coverage for certain plans (United Healthcare Fully Insured PPOs) to providers within the member’s service area, beginning on July 1. 

This change means that providers outside the member’s service area WILL NOT be reimbursed for services provided to patients under these plans.  You can access the full announcement through this link. To give you a sense of the impact this may have on your business: these plans represent ~30% of UHC members, and they tend to be the UHC plans with the lowest reimbursement rates.

Also, this guidance from Optum is subject to change or retraction; United recently attempted to implement a similar restriction on emergency room treatment, which was subsequently withdrawn after public backlash. We advise that you make sure your team is asking the appropriate questions on their VOBs to identify these plans, and flagging them for your team to be sure you are aware of any potential issues before a patient is admitted. 

If you’re not sure how to protect yourself against the negative impact of this change, we are standing by to advise or assist.  We are also offering a no-cost analysis of your payer mix to help quantify how much of your revenue may be at risk as a result of this change. Please contact our team through this link to find out more. 

As always, we remain committed to sharing any news that impacts revenue cycle management for behavioral healthcare and taking the necessary steps to protect our clients’ financial well-being. 

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