Delivery of Care

The problems with Optum continue

OHIC fines UnitedHealth $100,000 for how it is managing delivery of substance use treatments, determined by Optum

Photo by Richard Asinof/File photo

Patrick Tigue, R.I. OHIC Commissioner.

By Richard Asinof
Posted 4/4/22
The recent $100,000 fine levied by OHIC on UnitedHealth for problems with the way the health insurer made determinations around substance use treatment is really a fine against the way that Optum, which managed those determinations, made such decisions.
In the re-procurement of Managed Care Organizations in Rhode Island, will the use of Optum to make benefit determinations be seen as problematic? Would other health care reporters in Rhode Island be willing to become better schooled in how to report on health care topics? When will the Senate commission looking into R.I. EOHHS make its recommendations public?
The March 22 decision by the federal government to stop reimbursing for COVID-19 testing has left many health care providers in the lurch, particularly those who serve a high percentage of uninsured clients. With the rising numbers of the latest variant, COVID BA.2 Omicron, surging in the latest reporting on new cases, the breakdown of ongoing funding for surveillance measures for the transmissible virus would seem to be counter-productive.
For immuno-compromised patients, the decision is for how to receive a potential fifth shot, while others are considering a fourth shot for more protection heading into the summer.

PROVIDENCE – It should surprise no one that UnitedHealthcare was found by the R.I. Office of the Health Insurance Commissioner to have used criteria for determining “levels of care for substance use disorder treatment that were not consistent with Rhode Island law” and fined them $100,000 and directed them take action to fix the problem.

The $100,000 fine, announced on Wednesday, March 30, met with some predictable responses. Gov. Dan McKee issued a news release, saying: “Now more than ever, it is critical that our Administration hold health care entities accountable for ensuring parity between physical and behavioral health care.”

Exactly how the Governor proposes to hold health insurers accountable, particularly when the biggest problem with the delivery of mental health and behavioral health care in Rhode Island are the low Medicaid reimbursement rates being paid to providers, is unclear.

On the other side of the political spectrum, state Sen. Sam Bell, called the action by OHIC “another slap on the wrist from OHIC,” in a tweet in response to a news story in The Boston Globe about the fine. “This will mean nothing for a big insurance company like [UnitedHealth].”

The problem – with the Globe’s new story, the response by the Governor, and the response by Sen. Bell – is that the missing import of the story, and its potential relationship to the ongoing re-procurement for choosing Health Management Organizations for the managed Medicaid population in Rhode Island – is how UnitedHealth makes its determinations around levels of care.

Those determinations are made by Optum, a wholly-owned, for-profit subsidiary of UnitedHealth. That was confirmed by Cory King, chief of staff at OHIC, who wrote in response to a question from ConvergenceRI: “The benefit determinations were made by Optum.”

The problem arises in the fact that Optum has been deployed to manage benefit determinations for the two largest – by share of the population managed – current MCOs in Rhode Island, Neighborhood Health Plan of RI and UnitedHealthcare, who together manage some 271,000 out of 288,000 Medicaid members receiving managed care, apparently using 2020 numbers.

Translated, the use of Optum may not be optimal when dealing with behavioral health and mental health services for Rhode Island Medicaid members. Those concerns were raised in repeated testimony before the Senate legislative commission looking at the future organization of R.I. EOHHS. [See link below to ConvergenceRI story, “Is the role of Optum an optimal role?”]

Those concerns regarding Medicaid managed care organizations, however, fall outside the jurisdiction of OHIC, which is limited to commercial insurance companies.

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