Optum’s Requirements for Reimbursement of Timed Therapeutic Services

October 23, 2017
Rick Gawenda

UnitedHealth Group offers products and services through two operating businesses, UnitedHealthcare and Optum, both subsidiaries of UnitedHealth Group.

Optum include three divisions:

  • OptumInsight – Health Data Analytic, Payment Integrity, Life Science, Risk Quality & Network Solutions, Medical Billing
  • OptumRx – Pharmacy Benefit Manager (now includes all Unitedhealthcare membership) and Catamaran acquisition
  • OptumHealth – Healthcare delivery services and support including Consumer Solution Group and OptumCare (Behavioral Health and Substance Abuse, Dental, Vision, Transplant Management, and other ancillary services)

OptumHealth Care Solutions processes outpatient therapy claims and OptumHealth Care Solutions have several reimbursement policies pertaining to outpatient physical, occupational and speech therapy services. Three of the most frequent questions I receive regarding OptumHealth Care Solutions is:

  1. Do they follow Medicare’s billing guidelines (i.e. 8-minute rule)
  2. Do they limit how many time-based units they pay for on a given treatment day
  3. Do their policies also apply to me if I am an out-of-network provider.

In this article, I will answer these 3 questions and provide you with the resource and reference for my answers.

Does OptumHealth Care Solutions follow Medicare’s billing guidelines?

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  1. Thanks for the heads up as I was unaware of the Optum relationship with UnitedHealth group. Does it still hold true that we follow all Medicare documentation and billing guidelines for Medicare replacement plans, with the exception of G-Codes? To my knowledge G-codes are only required for Medicare B and Tricare. Can you confirm this?

    1. You would have to check with each Medicare Advantage plan to see what their billing and documentation requirements are for patients receiving outpatient therapy services.

  2. When UHC was just UHC our outpatient PT/OT/ST services were being reimbursed at a decent typical market rate but when they joined with Optum our reimbursement rate went to a flat fee and unacceptably low. The EOB’s state this is the rate I agreed to (and I assure you I have not agreed to it). I am getting the run around for answers as to when I signed an agreement for the ridiculous amount they wish to pay, the flat fee for treatment services, and if there has been a mistake. Do you have any suggestions on how to follow up on this or I will be forced to not accept UHC/Optum insurance clients. thanks

    1. You would need to look at the language in the contract you signed with UHC. My opinion is that it contains language that makes it applicable to OptumHealth.

  3. Are all UHC outpatient therapy claims processed through Optum Healthcare Solutions or just some of them?