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���������� Note: This article details a provider’s perspective of failures and inconsistencies with Optum managed behavioral health in Idaho. The issues are not rarely heard when critics voice concerns over how management companies will treat the needs of BH consumers. Long approval wait times, unpredictable reimbursement, and inappropriate clinical interventions are only part of the problem. One issue is that Optum is the only company in that state to be serving the BH needs of all Medicaid clients; without a competitive environment or accountability from a risk-bearing managed care company, the system may be less likely to be responsive to provider needs. Similarly, however, the problems raise questions about what some believe to be the preferred option of having BH managed by a company that specializes in it. If high standards are not placed on a plan by state agencies, and if those agencies are not responsive to the needs of providers and consumers, BH management will not succeed to reduce costs and integrate care. NY’s high expectation set for BH management in the request for MCO and HARP qualifications may yield more desirable outcomes, but not if the state relies on performance indications from other state markets to guide approval or readiness.

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Providers: Contractor’s Rules a ‘Travesty’ for Mental Health System

Times E-News; Drew Nash, 7/2/2014

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Mental and behavioral health-care providers hoped their pleas and legislators’ inquires would lead to fixes of systemic problems with Optum Idaho, the company overseeing the state’s low-income mental health program.

Six months later, nothing has changed, sources told the Times-News.

In fact, it’s worse, they report. Services to at-risk patients have been cut, wait times for approving care have lengthened, and Optum has created burdensome red tape that costs providers time and money .

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

“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 Proffered Child and Family Services.

Jones said he wasn’t comfortable discussing the letter’s contents, as it hasn’t been approved yet, but said a similar statewide coalition also is forming.

In mid-June, Crosspointe held a standing-room-only, 2½-hour meeting at with at least 50 providers from around Idaho, state Sen. Lee Heider, R-Twin Falls, and Optum officials.

“They were not responsive and just dismissed us,” Fullmer said of Optum brass.

In 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.”

Last September, Optum began managing outpatient mental, behavioral health and substance use services to those enrolled in Medicaid.

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 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 they will call back within 48 hours, Fullmer said.

It’s often longer than that, though, before a second person calls to schedule a time for the provider to state their case to a third person. That third person may call within a few weeks to eventually 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.”

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.“

Heider, chairman of the Senate’s Health and Welfare Committee, 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. Indeed, Optum “didn’t roll over and play dead” at the June meeting, he said, but both sides need to make changes.

“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,” he 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. There are ethical issues that licensed professionals need to address.”

For the past three months, Thompson said 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.” Calls inquiring about missed payments are simply not returned, he said.

“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 back 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 county’s 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.”

If poor service continues, providers will flee to other states with better systems — an exodus an already broken system can’t afford, Fullmer said.

“Optum’s profits last quarter were millions and millions of dollars, and I’m thinking: Our tax dollars are being used to pay this company to manage care; they are doing it poorly,” she said. “The care has been cut, and our tax dollars are going out of state … and we are not putting that money back into programs that our people need in this community. To me, that’s a travesty.”

While Heider is seeking a non-legislative solution, he said that may change. Optum is not a sacred cow.

“They, too, can be replaced,” he said. “There are providers out there that would love to take on Idaho’s behavioral mental health contract.”

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