Insurance

Optum Per-Visit Fee Schedule

Many of you have received a letter or letters from Optum over the last week or so describing a new “per-visit” fee schedule.  Optum has been rolling out this new payment model state-by-state beginning in late 2015.  The amount of the per-visit fee varies by state.  The $68 NJ per-visit fee is the highest allowance we are aware of thus far.

 There is a National Task Force of various stakeholders in the Chiropractic profession across the country which has been working to combat this change for over a year.  The ANJC has been participating in this Task Force and has sent a letter to the NJ Dept. of Banking and Insurance raising our opposition to this new payment system on legal and regulatory grounds.   We have yet to receive a response from DOBI and have sent a follow up letter requesting their response/opinion on this matter.

 A few key points about this change:

• The change takes effect on February 1^st 2017
• At this time this change only affects in-network
• With the implementation of this per visit fee, the Optum fee-for-service fee schedule will be going away.   The billed amounts from the doctor’s office will be allowed up to the per-visit limit.
  In other words, if your office’s standard charge for 98941 is $60 and that is all that you bill on that date of service, then your reimbursement will be $60.
  If your office’s standard charge for 98941 is $70 and that is all that you bill on that date of service your total reimbursement will be the per visit fee of $68. 
• The $68 per visit fee includes all services; CMT, therapies, modalities,  E/M services, radiology, laboratory services. 
• The letter lists a “Medicare Fee Schedule Description” below the per-visit fee.  It is IMPORTANT to note that these fees for 98940-98942 are referring to the reimbursement for Medicare Advantage Plans under United Healthcare ONLY.  Your CMT codes will not be capped at these rates under the commercial per-visit fee. 
• You may have received two similar letters on this matter.  One letter shows the Medicare Advantage fee schedule for UHC Medicare Advantage products and the other shows the Oxford Medicare Advantage Fee schedule.  This is the only difference in the letters to our knowledge. 
• With this change to the per-visit fee schedule, Optum claims to be eliminating all post-payment audit and recovery for in-network providers. 

 The ANJC is meeting with representatives from Optum next week.  We will provide more information and education on this change in the near future.