Pre-Payment Review is the New Prior Authorization

And it's probably a violation of Mental Health Parity Law

Oh my. I made the mistake of making another video about United healthcare on TikTok, and of course it blew up. I was reporting a factual matter—United healthcare is suing the US government to the downgrading of their CMS rating, which negatively impacts their reimbursement and Medicare advantage plans.

The comments about a matter of fact? Savage. United healthcare might be the most hated company on earth. Oil companies and tobacco companies don't get this kind of vitriol—at the very least, they're smart enough to get chills to support them even when other people are calling them out?

United health group doesn't seem to bother… here is a sampling of responses:

“I loathe UHC, Medicare, and UHC community Medicaid with everything in me. I've filed reports against UHC community here in Ohio for failure to pay. Once the state gets involved, they rushed stuff through.”

Or:

“I had the misfortune of having United healthcare in the past and spent more time fighting with them to get paid claims and I spent with my actual doctor”

Or:

“F United healthcare—their evil, denies medically necessary services that should be covered under their plan and padded the bills they sent to Medicare for taking care of beneficiaries.”

And:

“Stop saying healthcare. It's only corporate greed.”

And also:

“yeah! Discovery! Every single email between reps and doctors office. I can zip through those and categorize and summarize them, then counter sue on the peoples behalf.”

Then there is this:

“Unfortunately, healthcare professionals are not willing to accept United healthcare due to their lack of coverage.”

Or:

“They will lose”

And of course:

“you mean the company that tripled healthcare for months due to improper cyber security? Leading to poor patient care? Yeah, they can pound sand.”

Or:

“the amount of Hatred I have for the CEOs and board members is wild. Like I don't know what I do if I met one of them in person. I would go to jail for attempted manslaughter if I failed. These people are scum.”

There was one (and only one of 52 total) positive comment:

“I switched United healthcare and has been great. They cover my medication's with only two requiring prior authorization. It was the best decision.”

To which somebody responded: “I used to feel this way. Get on the wrong side of their AI claims processing or need to speak with someone who can help you with issues who can do anything and you're probably gonna have new feelings.”

I think it's remarkably fair to say that United healthcare has a PR problem? Other companies have to care about press problems because they have to sell a product to someone, who, in turn, has to choose to buy it. United healthcare? They don't have that problem. There's less individual choice in the healthcare marketplace. What does matter for their business is their ability to increase their quarterly profits, which are currently in the astronomical range of more than 5,000,000,000 dollars every quarter. And that has to go up to keep Wall Street Happy. It has to go up every quarter.

Prior authorization has been a mainstay of profit maximization for reasons I've explained previously. But recently, prior authorization has come under scrutiny, and so they need to come up with new and more creative names for how they're going to decide what money they spend. The amount needs to be more and it can't ever be less, so it's important that they stop paying for things that could possibly drive down cost, and only pay for things that increase cost. But the most important thing? The payer needs to have the option to pay or not pay at any given moment. This keeps a Medical Loss Ratio in perfect sync with profits! That has now been solved.

It's been solved with the process of being called prepayment review, and my colleague at Clear Healthcare Costs has been diligently documenting this remarkably complicated process. It’s worth reading. Here is an excerpt:

The listserv email he forwarded is titled “How to stop Optum med records requests.” It reads: “For those of you being audited:

“Once you start complying with sending records, you can do this every 60 days. It is possible you have to wait 90 days the first time before requesting this (below) however then you can do it every 60 days until you get the 80% score and the audit will stop. 

“Call provider services at 877-972-8844. That is the PNI department (whatever that means). You’ll need to give your EIN / tax ID so they locate you as a provider. 

“When you get a rep on the line: request they run your compliance score.  It will take 24-72 hours for Optum to run your number. 

“If you are at 80% or above they will stop this audit for your practice. 

“You can ask them to email you or you can simply call back to find out the result and what your number is.

“You can also ask them to send the report to you so you can see exactly what’s going on with what you’ve submitted to substantiate your score.”

Oh…my. No, no thank you. But for UHC? It’s not an optional requirement.