Wake County mental health providers say they're owed thousands in insurance claims

WAKE COUNTY, N.C. (WTVD) -- Several Wake County mental health providers tell the Troubleshooter that they're frustrated as they wait for thousands of dollars in insurance payments. These payments are for services that they say have already been given to patients.

Therapist Mary Affee, owner of Horizon Integrated Wellness Group PLLC said the amount she is owed in claims is close to $11,000.

"The pile sitting here has not been paid and I have a brand new stack, probably 50 patients that I have to add to the pile," Affee said.

She said this all started in November when her Cary office received a letter from Optum, UnitedHealthcare letting her practice know they're verifying services that were provided to their patients to ensure proper billing.

Affee said she doesn't mind Optum verifying claims but said the amount of claims they're questioning is excessive.

"This just is very frustrating and very overwhelming to then have to fight for services that were rendered and then still see our patients," she said. "I don't want to see anything to happen to any of my patients."

Raleigh's Stephanie Phillips, owner of The Mindly Group PLLC, is facing the same frustrations when it comes to UnitedHealthcare client's claims getting denied, despite services already given to patients.

She said she has at least 322 claims under review by Optum, which amounts to $23,992 of unpaid claims.

"It's very hard because my clinicians are getting paid. I am paying them on faith that I'm going to get paid," Phillips said.

She also received the same letter from Optum letting her know the claims filed by her office would be under review.

"So they asked us to send them specific information that I saw them on that date and time, and I complied with everything," she said. "Thousands of pages of faxes. They came back and said, oh it's wrong or not enough."

Both Phillips, Affee, and several other mental health providers told the Troubleshooter that claims that are being questioned are for 60-minute sessions.

They said when it comes to UnitedHealthcare insured patients, those sessions would get approved and paid electronically, but since November, providers said they're spending hours re-submitting those claims to the insurance company.

"I feel that I really had to pull back on client care in terms of seeing the patients or caseload that I have here because I have to devote the time here," Affee said.

Besides spending the time to re-file the claims, Phillips said her patients need those one-hour sessions.

"We use that last 15 minutes to transition them back," Phillips said. "You know, I have clients in tears, who are anxious, and I use those 15 minutes to go back into the world and I can't do that in 45 minutes."

The Troubleshooter reached out to UnitedHealthcare and a representative with Optum said, "To promote greater access to care with fewer administrative burdens for our members and providers, Optum removed prior authorization requirements to 60-minute therapy sessions under the 90837 billing code in Dec. 2018, which are typically reserved for more complex clinical cases that require additional time.

"At the same time, we are also responsible to ensure appropriate billing and payment are consistent with member's health plan, national guidelines, and federal and state laws. As such, a limited number of providers, approximately 0.36 percent of all providers nationwide, are asked to submit additional documentation prior to payment under this specific code, which they were notified in November 2019. Once the additional documentation is submitted, we generally adjudicate these claims within a couple of weeks."


The representative added they are working directly with the providers. Both Phillips and Affee said they are slowly getting paid on some claims, but then others get denied.

We will keep you updated.
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