Mental health providers fault Idaho payment overseer

They're renewing months-old gripes about Optum Idaho, which serves Idaho's Medicaid program.


Optum Healthcare Hold Times

Front desk supervisor Jane Reali calls Optum Health for a form and treatment plan authorization Thursday at Crosspointe Family Services in Twin Falls. Optum this week changed its approach for authorizations the and directed Reali to a website. While providers are angry with Optum, Reali was surprised by how fast the new process works.

DREW NASH — Times-News (Twin Falls)

CORRECTION: This story originally misspelled the name of the provider Eric Jones co-owns, Preferred Child and Family Services.

Mental and behavioral health care providers hoped their pleas and legislators' inquires last winter would lead to corrections of systemic problems with Optum Idaho, the company that has overseen the state's low-income mental health program since September.

Six months later, nothing has changed, providers say. In fact, they say it's worse: Services to at-risk patients have been cut, wait times for approving care have increased, lengthy approval processes often are changed, and Optum has created burdensome red tape that costs providers time and money.

For months, the businesses have grown increasingly frustrated by the Eden Prairie, Minn., company's management of the state's outpatient mental, behavioral health and substance use services to those enrolled in Medicaid. The services can include counseling, therapy and case management.

The ultimate detriment, however, is to at-risk patients, said Jennie Fullmer, co-owner of Crosspointe Family Services in Twin Falls.

"There's a more crisis-type need now, because services that would keep patients stabilized have been reduced, and patients don't have as great an access to care," Fullmer said.

More than 20 providers have formed a regional group to draft a letter of concern to Optum and state lawmakers, said Eric Jones, co-owner of Preferred Child and Family Services of Twin Falls. Jones said a statewide coalition is forming, too.

In mid-June, Crosspointe held a standing-room-only meeting with at least 50 providers from around Idaho and Optum officials. "They were not responsive and just dismissed us," Fullmer said.

In a statement Tuesday, Optum officials said they were "committed to working with Idaho's behavioral health care providers to ensure people get the right care at the right time and place, with a shared goal of helping people reach long-term recovery."

Eight providers attended a follow-up meeting Wednesday with Optum that was announced Tuesday afternoon so Optum could listen to provider feedback.

Many couldn't on such short notice, said Stacy Stephens, owner of Alliance Family Services.

"That is just another way for you guys (Optum) to make us feel like crap," she said at the meeting. "(Optum is saying) 'We don't value your time, we don't value anything about you, but we are going to throw you a little bone here, but we are going to give you less than 24 hours' notice.' "


Audrey Palmer, Optum's regional network manager, listened as providers said Optum's changes and cuts have caused the hospitalization and incarceration of clients, especially at-risk children.

Palmer promised to address providers' concerns by running them up the chain. "The biggest thing is that I'm here and I'm listening," Palmer said.

Her comments didn't appease providers. "You have heard this all before, but nothing has changed," said Mark Gritton, a counselor with Crosspointe.

Crosspointe and others can provide counseling immediately to those in a crisis, but they need Optum to sign off on an increased level of care. In January, providers told lawmakers they were sometimes kept on hold on the telephone for up to seven hours to get Optum's approval.

Now providers call and talk to a person at Optum right away, but that person is a "human answering machine" who tells the provider he or she will call back within 48 hours, Fullmer told the Times-News for a story published Wednesday, before the latest meeting.

The wait is often longer than that, though, before a second person calls to schedule a time for the provider to state a case to a third person. That third person may call within a few weeks to decide whether Crosspointe can treat the client, she said.

"For someone coming out of the hospital, two weeks (of waiting) is ridiculous," Fullmer said.


Scott Thompson, co-owner of Healthy Progression of Twin Falls, said he actually preferred the old system of multiple-hour wait times: "At least when they answered the phone, we got some results."

On Tuesday, Optum again started a new, online authorization system, he said. The online form takes at least an hour to fill out, depending on how "wordy" providers want to get. "The wordier you are, the better chances we have of getting these clients services," Thompson said.

"At least I don't have to worry about staying on the phone all day. I can go work with my clients in the day and stay up all night typing these up."

State Sen. Lee Heider, R-Twin Falls, chairman of the Senate's Health and Welfare Committee, attended the June meeting.

He said he thought the Legislature had fixed the problems with Optum months ago, "but now we are in that same boat again."

Now Heider again is trying to broker a better system between Optum and providers.

"I don't know how Optum thinks they can evaluate the situation from Boise or Indianapolis or wherever they happen to be when the person is sitting with someone in their office in Twin Falls understanding the crisis that this person is in," Heider said.

"So I'm leaning on the side of the providers, trying to help them to get Optum to authorize payment for the methodology they think is appropriate."


Thompson agreed, "We see firsthand the need for these services, and you have someone from Pennsylvania just saying, 'Mmm, nope. We don't think that's bad enough.' "

Fullmer said some Optum responses to requests for service authorization have raised ethical flags.

"I can tell you that providers are now recording phone calls, because it is a blatant disregard for clinical information," she said. "They are telling us how to treat patients they have never seen before."

Palmer said at Wednesday's meeting, "Nobody should be making clinical decisions for you, and if they are, I'd like to talk to them."

For the past three months, Thompson told the Times-News, he has not been able to bring on any new clients because Optum keeps rejecting his requests. Healthy Progression focuses on youth behavioral health.


Moreover, Optum's reimbursement levels are "very inconsistent," he said, and calls inquiring about missed payments are simply not returned.

"Say we bill Optum $1,000 a week. One week we'll get $50 back. The next we'll get the full $1,000," he said. "It is pretty hard to run a business when you don't know what you are going to get back."

By cutting services to save costs in the short term, Optum is deferring the real, long-term cost of mental illness to taxpayers and pocketing the difference, Fullmer and Thompson said.

Many underserved mentally ill end up in the emergency room or jail - high-dollar holding tanks that rarely fix patients' underlying conditions, leaving taxpayers to pick up the bill through their counties' indigent-care services.

"If Optum continues to make these cuts, there will be more crisis mode," Thompson said. "The detention centers, the state hospitals, the crime will all rise."

The Idaho Statesman contributed.

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