Reconciliation and Recoupment Plans for Estimated Claims Payment Period for United Health Group (UHG) / Optum Behavioral Health Providers (Optum)
The Maryland Department of Health (MDH) is preparing to enter into the next phase of reconciliation to resolve the differences in the estimated claims paid from January 1, 2020 through August, 3, 2020, with actual claims submitted for those dates of service.
In contrast to the initial rollout, the UHG/Optum Maryland system has improved dramatically – additional enhancements continue to be made to ensure that providers are accurately and promptly paid for all services provided, and the vast majority of providers are successfully submitting authorizations and claims and are getting paid for the vital services they provide.
UHG/Optum has so far received nearly 17 million claims between January 2020 through August 2021 and has successfully paid nearly $2.9 billion associated with those claims to over 2,600 providers who participate in the Public Behavioral Health System. UHG /Optum is currently paying out an average of $30-$40 million a week to providers based on actual claims for care.
Overall, 98 percent of all provider claims are being adjudicated within 14 days – numbers that are consistent with the experience with the old payment system and are within industry standards.
Beginning on October 24, 2021, MDH anticipates that all of the remaining 835 and Provider Remittance Advice (PRA) reports required for providers to complete any internal reconciliation needed between actual claims submitted and payments from the estimated claims payment period will have been delivered.
The state has a legal and moral responsibility to Maryland taxpayers to recoup these funds, and the time has come to enact a repayment plan that both recognizes this responsibility while making the appropriate allowances to providers. With that in mind, we do not plan to initiate formal recoupment of balances owed until providers have had a reasonable amount of time to reconcile their internal accounting. We estimate that recoupment will begin on or around December 1, 2021.
Moving Forward on Reconciliation
Currently, providers have received approximately $237 million in excess payments during this process, which some have already repaid and many others are working to repay.
In recognition of the challenge caused by repayment, MDH will be forgiving the debt for eligible providers owing $10,000 or less. As a result, more than 42 percent of providers with outstanding balances due will owe nothing. Hopefully, this will eliminate the burden on small, community-based providers. All providers owing $10,000 or less will have their balances cleared with the exception of the following provider types:
Somatic BH Health Providers
Providers who have not yet submitted claims against any of the estimated claims paid.
This plan will have repayment options for those providers owing more than $10,000. They will have one of three options for repayment:
Payment in full at time of notice.
The option to credit current claims paid to off set all or some of the balance sowed over a 12-month period, with final payment to be completed within twelve months.
For providers with outstanding or fully paid balances of between $10,001 and $50,000, we will engage the provider community and will evaluate providing additional relief.
We value our relationship with the Behavioral Health Community and are thankful for the critical services you have continued to provide during this challenging time for all Marylanders in need, especially our most vulnerable populations.
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