In this article, we will go through FAQs that address common questions you may have about the new Optum utilization management reviews for Medicare Advantage patients. We will cover topics such as the duration of each review, preparation tips, and the process that follows the review.
FAQs
What is happening with Optum Medicare Advantage (MA) reviews?
Optum will begin conducting telephonic quality and utilization reviews for select MA therapy clients. These are standard reviews designed to ensure ongoing care meets medical necessity criteria for ongoing coverage.
How will I know if I’ve been selected?
Rula will notify you directly via email if one of your clients is selected.
How will I be contacted by Optum?
Optum will reach out to you directly by phone. If you are in session or otherwise unavailable, they will leave a confidential voicemail outlining the review request.
How do I know if I have any Optum patients in my caseload?
If you received Rula’s initial email about Optum reviews, you have at least one Optum MA client. Some payer information appears in the provider portal, but not all. We’re unable to provide a caseload list by insurance plan, but no action is needed at this time. Rula will notify you if one of your clients is selected.
How long does each review take?
Each live review call lasts 10–15 minutes.
What should I be prepared to discuss?
Be ready to summarize key details of your work with the client, including:
- The client’s diagnosis and precipitating event for treatment
- Functional impairments and measurable treatment goals
- Progress to date and projected outcomes
- Medication updates and coordination with any prescribers
In advance of the call with Optum, please be sure to familiarize yourself with what constitutes medical necessity for outpatient therapy services, so that you are prepared to represent how your client meets medical necessity to the clinical reviewer.
What happens after the review?
If the treatment appears to fall outside Medicare’s coverage guidelines, the case will move to a second-level peer review for a final clinical determination. You may request this review to be based solely on the case information Optum has access to. Please be aware that this does not include your clinical documentation.
What if I miss the call?
Optum will call twice and leave a voicemail if you’re unavailable. You’ll have a maximum of 7 days after the second outreach to complete the review before it’s escalated for peer review based on available case information.
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