The leading practice resource for behavioral health providers — since 1974

Volume 35, No. 11, Issue 427
November, 2009

FEEDBACK:  Answers to your questions about billing mishaps

QUESTION:  “I have a Blue Cross/Blue Shield patient whose behavioral health benefits are administered by OptumHealth Behavioral Solutions.  I file my claims with Optum, and BC/BS pays.  I’m on-panel with both companies.  Everything worked fine for two months—January and February of 2009.  Since then, I haven’t been paid.  Optum indicates they’ve received all of the bills, and they say they’ve transmitted them to BC/BS.  But BC/BS says they never got them.

“I’ve gotten an Optum provider relations person involved, and she said she has a ‘special claims unit’ working on it.  But now, she’s not calling me back anymore.  There are 24 sessions that I haven’t been paid for—going back to March, 2009.  What do I do?”

What went wrong, and what can you do about it?

   In the “Feedback” question nearby, a PsyFin reader spells out a severe billing problem. Here, three mental health billers give us their take. We’ve included a lot of detail because while they’re responding to a particular situation, these answers apply to a wide variety of problems that providers run into routinely.
   (Note: OptumHealth Behavioral Soutions is a brand operating under United Behavioral Health (UBH), Optum, United, and UBH are referred to interchangeably below.)

   • Tara Thomas, T&T Medical Billing, Chester, NY: “The way that OptumHealth usually works is that they give 10 pass-through visits. But after the tenth, they would require him to get an authorization.
   “And that would require him to fill out an outpatient treatment report (OTR). I’m better that’s what the situation is. It could be that someone gave him misinformation, or that no one told him he had to send in the OTR. It happens all the time.”

   • Jean Thoensen, PsychBiller, Centreville, VA: “First of all, if he’s talking to Provider Relations at UBH, he should find another person to talk to. Provider Relations only deals with contracting and credentialing. They know nothing about claims, and wouldn’t have an informed opinion about whether he should be paid or not. He should try ‘Provider Services’ instead.
   “Next, since BC/BS says they don’t have the claims, call UBH and tell them to forward them again. And considering the number of claims involved, getting a manager involved is preferable. The trouble is, UBH seems to be using off-shore reps sometimes, and getting a manager is impossible or takes an interminable length of time.
   “Finally, if possible, get the patient involved. Have the patient call UBH with a list of dates of service, and ask for the status of the claims. Member Services will often be more responsive to a patient complaint.
   “If the patient works for a big national employer, it’s undoubtedly a self-funded plan. So don’t bother trying to call the state Department of Insurance. Under ERISA, they’d have no jurisdiction over the plan…That could be part of the problem, if it involves the step of the employer funding the claims by paying Blue Cross/Blue Shield. If that’s the case, BC/BS won’t pay until they get paid by the employer.”

   • Susan Frager, Psych Administrative Partners, Lacey, WA: “My opinion is that Optum is the problem. (Rather than Blue Cross/Blue Shield.) They are responsible for repricing and forwarding the claims…United is such a behemoth now. I think we’re seeing with [them] what we saw with Magellan 10 years ago—too many acquisitions made too fast. Sometimes United claims, even those submitted electronically, just get misrouted within the company. And carveouts involving other companies tend to be most problematic.
   “Another thing: since this is a network provider, he has access to UBH online. It’s actually a pretty good system, and easy to use. You can track your claims status online, verify benefits, get authorizations, etc. You can even talk to a provider service rep online via web chat.
   “I would strongly recommend he file claims that way. You get a confirmation number which prevents them from saying, ‘We never got the claim,’ and then denying due to timely filing. By waiting so long, he’s going to have a ‘timely filing’ fight about some of those older claims.”

   Contacts: 1) Susan Frager, Lacey, WA, (360)628-8612,; Jean Thoensen, Centreville, VA, (703)266-8612,; 3) Tara Thomas, Chester, NY, (888)364-3858,