# United Healthcare/UBH/Optum medical records requests



## Cavalier40 (Nov 27, 2015)

I am having an issue with UBH/Optum. 

Basically if the facility treatment does not require UR/Prior auth, then we will get a medical records request for every claim submitted. I have confirmed that we are not under audit, and when we do have an auth number, we have no problem getting paid. I feel this is a malicious obfuscation of paying claims and a violation of the minimum necessary standard of HIPAA. 

We have been complying with the requests, however the records never seem to get attached to the claims, or we are told they are sent to the wrong address. (even though we send to the address on the correspondence) When they do get the records, we are told they are incomplete, or they were not received timely. Sometimes we are told that medical necessity is not met, but we are never given an explanation of what standard is not met and where the records are deficient. 

The only answer I hear from the off shore call center is that our per diem rate is too high. I think this is incorrect since we are out of network and do not accept assignment, the vast majority of the claims are sent to Multiplan for repricing. 

This is wrong to the point of being criminal, however since all UHC plans are self funded, they hide behind ERISA. 

Does anyone have any insight or solution? That would be greatly appreciated.


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## Missy13 (Dec 8, 2015)

We were getting the same medical records request from them, which turned out to be no authorization rejection. We were told by the representative that 90837 requires the authorization but 90834 does not, and that we can bill 90834 with 90785 (interactive complexity) to supplement for the difference. We did resubmit the rejections with 90834 and 90785 and got paid. 

On the other hand I am not sure if this is right thing to do for no authorization for the future claims. That is why I am here on this website trying to find out more about it, but I am going to place a call to Optum again to see if I can have anything in writing. I would like to know more rules and documentation rules on billing this code. If anyone is familiar with it please let us know. 

Thanks


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## hopepg (Dec 8, 2015)

We are having same issue with UHC. We have a bigger problem with Humana (commercial & Medicare Advantage). I occasionally see with Aetna & BCBS. No matter if we have a pre-certification/prior authorization for the services. 

Get the payer's fax numbers & send that way. Or, some payer's online provider portals have a way to upload records that way. Or if you have the letter or notice they send where they are requesting the records, always send that letter or notice with the records. Use it as a cover sheet. 

It's my opinion that they are just claim payment stall tactics. Just keep at it, follow up quickly & keep bugging them until you get payment!


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## rmancine (May 19, 2016)

*Billing*

We are having a major problem with UHC requesting records.  We are a Specialists Group and also Non-Par.  UHC is only requesting Hospitals records, but they are sometimes requesting them on 4-5 patients a day. We are also experiencing many of the same issues as listed above and have started reviewing/auditing all records before they are sent to make sure the records support the billing-which they do.  We are also keeping a spreadsheet of all records requests, dates, when records were sent, and outcome.  This is getting very frustrating and there has to be a solution (or at least there should be).  Any ideas or comments?  Thank you


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## CodingKing (May 19, 2016)

rmancine said:


> We are having a major problem with UHC requesting records.  We are a Specialists Group and also Non-Par.  UHC is only requesting Hospitals records, but they are sometimes requesting them on 4-5 patients a day. We are also experiencing many of the same issues as listed above and have started reviewing/auditing all records before they are sent to make sure the records support the billing-which they do.  We are also keeping a spreadsheet of all records requests, dates, when records were sent, and outcome.  This is getting very frustrating and there has to be a solution (or at least there should be).  Any ideas or comments?  Thank you



The payer has every right to request the medical records so there really isn't much you can do. There is a major increase in fraud in non-par behavioral health/substance abuse providers so i'm not shocked. You can always turn non-par patients down (except in emergencies under EMTALA) There is no requirement that you accept their insurance. Its just what you need to deal with if you don't want to contract with insurers.


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## Cavalier40 (May 24, 2016)

Missy13 said:


> We were getting the same medical records request from them, which turned out to be no authorization rejection. We were told by the representative that 90837 requires the authorization but 90834 does not, and that we can bill 90834 with 90785 (interactive complexity) to supplement for the difference. We did resubmit the rejections with 90834 and 90785 and got paid.
> 
> On the other hand I am not sure if this is right thing to do for no authorization for the future claims. That is why I am here on this website trying to find out more about it, but I am going to place a call to Optum again to see if I can have anything in writing. I would like to know more rules and documentation rules on billing this code. If anyone is familiar with it please let us know.
> 
> Thanks



I would agree this is not the right ting to do. In order to bill for interactive complexity, you have to meet one of the criteria which are:

1. Maladaptive communication
2. Caregiver emotions/behavior that interfere with implementation of the treatment plan
3. Evidence/disclosure of a sentinel event and mandated report to a third party with initiation of discussion of the sentinel event and/or report with patient and other visit participants
4. Use of play equipment, other physical devices, interpreter or translator to communicate with the patient

I have also been told that interactive complexity can be used for EMDR type therapy sessions as well. 

If you have good documentation of the time stamp on the 90837 code, you could possible win on appeal.


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## Cavalier40 (May 24, 2016)

CodingKing said:


> The payer has every right to request the medical records so there really isn't much you can do. There is a major increase in fraud in non-par behavioral health/substance abuse providers so i'm not shocked. You can always turn non-par patients down (except in emergencies under EMTALA) There is no requirement that you accept their insurance. Its just what you need to deal with if you don't want to contract with insurers.



If payers would give an in network per diem rate that was acceptable, I would contract in a minute. However with the contracted rates they offer, a SA facility would need to keep 100 beds full all the time just to turn a profit. Since the vast majority of treatment centers are 100% non par, not accepting an insurance is most of the time not an option. 

The issue I have is the blanket requests, assuming all providers are fraudulent. We have always presented good records and even survived a SIU audit from Optum, so they already know they are doing things right. Also when they first send the request, notes such as the treatment plans and initial psych and medical visits are already sent, but if they are not included on all the notes, they consider the notes incomplete so we have to send them the same notes as much as 20 times. I also have an issue with the address roulette and not actually processing the records when received. This is not an attempt to verify that the services were rendered as billed, it is a blatant attempt to delay and deny payment.


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## campglo (May 24, 2016)

*Uhc medical records*

We are also experiencing the same thing with them. I have found the request they send over with the barcode and the information of the request and fax has a totally different claim# then the claims denying on the EOB stating missing information has not been received . I know they were in a back log of 2 months as of Feb 2016 of processing records. They have been auditing OON substance abuse facilities and truly concerned about the Urinary Drug screening. I send them all information such as pyshc eval, doc orders, progress notes, treatment plans , UA results and still get the Medical documentation was not supported denial.


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## MJohnsonMartinez (Jul 25, 2016)

*90837 -- not covered*

We have also found we cannot bill a 90837 with United - as they will not pay without medical records.


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## danskangel313 (Jul 25, 2016)

MJohnsonMartinez said:


> We have also found we cannot bill a 90837 with United - as they will not pay without medical records.



With any payer, I believe you have to get specific authorization SIGNED by the patient to release _psychotherapy_ notes. I know we've always had to do so. (As well as for HIV/AIDS and genetic information).

This is from CMS:

"Psychotherapy notes are treated differently from other mental health information both because they contain particularly sensitive information and because they are the personal notes of the therapist that typically are not required or useful for treatment, payment, or health care operations purposes, other than by the mental health professional who created the notes. Therefore, with few exceptions, the Privacy Rule requires a covered entity to obtain a patient’s authorization prior to a disclosure of psychotherapy notes for any reason, including a disclosure for treatment purposes to a health care provider other than the originator of the notes. See 45 CFR 164.508(a)(2). "

"An insurance company cannot obtain psychotherapy notes without the patient’s authorization. And _the insurance company is not permitted to condition reimbursement on receipt of the patient’s authorization for disclosure of psychotherapy notes_."

So if you're getting asked to send them psychotherapy notes (specifically), then you need to get an authorization from the patient to release them, AND UHC/UHB/Optum can't use any refusal to release the records to justify a denial or non payment. IMO, if you're getting slammed with requests for medical documentation, I'd respond, IN WRITING via MAIL with RETURN RECEIPT, asking for an explanation as to why they require such records and that they need to provide proof that the patient has agreed via a signed release of authorization that they agree to have such information released. I wouldn't mention anything about the Privacy Rule... I'd keep that in my back pocket until they respond.

It's always been my experience with any UHC-related entity that they try to dodge rules and so on by discussing issues on the phone, so anytime they want to talk about something, we only accept it in writing. They are notorious for riding the Float as long as they can.

Why are they denying 90837? What's the reason on the RA?


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## danskangel313 (Jul 25, 2016)

campglo said:


> We are also experiencing the same thing with them. I have found the request they send over with the barcode and the information of the request and fax has a totally different claim# then the claims denying on the EOB stating missing information has not been received . I know they were in a back log of 2 months as of Feb 2016 of processing records. They have been auditing OON substance abuse facilities and truly concerned about the Urinary Drug screening. I send them all information such as pyshc eval, doc orders, progress notes, treatment plans , UA results and still get the Medical documentation was not supported denial.



Hit 'em with a Clean Claim violation. Back log doesn't override the Clean Claim rule.


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## robertjsenese (Aug 31, 2016)

danskangel313 said:


> Hit 'em with a Clean Claim violation. Back log doesn't override the Clean Claim rule.



I don't see how the clean claim would work in this case- because the documention UHC sends states it is "under review for medical necessity." 

Also clean claims do not cover places that are under investigation for "fraud and abuse". 
So then if you play that card, then all they need to do is send a letter from the SIU, and they are in the clear- if I am correct. 

The "sent to the wrong address" appears to be a stall titc for he simple fact that most places experience this.  They request medical records within 45 days of the addressed letter,  then say they never received them. The only solution is send records with a tracking number, or get a fax number and send with a efax, so there is a log. But they still take forever to pay.


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## gailg929 (Feb 22, 2019)

*same problem-I filed complaint w/Dept of Insurance*

I have the same problem. We get authorization for surgery - and bill out the exact codes that were approved. UHC already rec'd the records in order for us to get the authorization. About 3 weeks after the bill goes out, we get a request for records. I have complained to PrthoNet/UHC. I have filed complaints with the Dept. of Insurance. United Healthcare claims that they review the records to ensure the surgery was warrrented. I told them that we sent records in order to obtain the approval. I was then told that the letter of approval is "Not a guarentee of payment". I asked them if I am to tell the patient that? That after we have gotten approval, that the charges still may not be paid and they will be held liable? United Healthcare tells me to not tell the patient that.

There is no way around it


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