Many wise individuals have said, “The only constant thing in life is change!” This same phrase applies to the healthcare industry. Recently, Optum announced major changes/ updates to the member service coverage in a plan designed for members of United Healthcare’s (UHC) fully insured plans. Effective July 1 20201 , Optum Fully insured plans will exclude benefits provided to members outside of their service area as defined in their member certificate of coverage. This change applies to medical and behavioral health services (Psychiatric and/or Substance Use) and impacts services that are already subject to prior authorization. This change in coverage is causing providers all across the nation to ask questions of how this will impact their patients, their businesses and their future!

What/whom does this “change” apply to?

For behavioral health services administered by Optum, the service area change applies to:

  • PHP or IOP facilities
  • Freestanding Facilities
  • Residential Treatment Centers (Inpatient facilities, Detox’s, etc.)
  • Inpatient Rehabilitation Facilities

According to this new rule Optum members who are “Fully-Insured” plans as compared to  “Self-Funded” plans will not be able to get covered underneath the plan’s benefits for services outside of their “service area” or coverage area. Optum’s representatives defined the service area as the state where the covered individual is currently a legal resident. This is technically means that geographic area restriction is now in place which  will require members (patients) to seek a provider within their service area, regardless of if the provider is in network or out of network participating with Optum.

How will these new changes impact providers?

There is a lot of uncertainty around the new updates and providers need to be diligent when verifying benefits and coverage and ask adequate policy related questions to ensure reimbursement for the services rendered to the patients. If providers are going to be delivering care to patients who have “fully-insured” plans then they must take extra precautions by working with reputable billing companies who can help guide them through this process and better understand what impact this will bring to their businesses. Without a proper understanding from a knowledgeable and educated biller, healthcare providers could be making decisions that can financially effect the members.

How does this impact patients?

Optum members need to understand the type of policy they hold, whether it is a fully insured or self-funded policy. Understanding the type of plan is helpful when finding what provider are covered underneath their benefits and what impact it will bring in regards to their out of pocket medical expenses. Even if the member has a fully insured plan but is not seeking services within the service area, they might not be covered for any of the services provided to them, which can result with them having to bear the expense of a large medical bill.

General Consultation help at Statim

Statim, has dedicated staff members who can help and guide you through this new policy change so that your business can make the proper decisions to increase its quality of care, efficiencies and revenue . Consult or talk to our trained, professional, dedicated billing consultants, to better understand how the new policy changes can affect a patient as well as providers.

Our committed team at Statim – Medical Billing Company in California have already done their due-diligence and talked to Optum representatives to understand the new policy and the challenges it can pose to the providers and members/patients. We have identified different types of policies and the restrictions imposed due to the new changes and would love to educated you through this new process.