Is Optum real for real?

At the annual HLTH conference in Las Vegas this week, Optum, the data analytics subsidiary of UnitedHealth Group, announced the launch of Optum Real, a real-time claims management system designed to eliminate friction between providers and payers when it comes to submitting claims and getting reimbursed in a timely manner.

The announcement comes not a moment too soon, given that provider resentment against what they see as a “delay and deny” policy from insurers has reached a boiling point. Company executives took the stage at HLTH to explain how the vast majority of claims are processed quickly and only a few give people headaches. The reason is: the lack of transparency.

“If I have to sum it up in one word, I would say the biggest challenge in claims and reimbursement is guesswork,” Puneet Maheshwari, senior vice president and general manager of Optum Real, told the audience on Tuesday. “Uncertainties that occur on the provider side. Uncertainties that occur on the payer side result in a significant amount of work and overhead for both parties involved…”

Enter Optum Real.

According to the Minnesota company’s press release, Optum Real is a “multi-payer platform” [that] enables real-time data exchange between payers and providers, enabling the identification and interception of known issues at the time of claim submission. Given that Optum developed the system that promises “instant clarity,” it’s no surprise that UnitedHealthcare, a sister company under the UHG umbrella, is the first health plan in the country to adopt this technology.

In an interview after the onstage panel discussion, Maheshwari said Optum Real was designed to remove the data fragmentation that hinders the claims adjudication process and can save the millions of dollars providers pay to clinical documentation improvement teams to increase their chances of getting reimbursements and the millions of dollars payers pay to claims integration companies to ensure that the service providers do everything according to the rules. Here’s a lightly edited Q&A of the discussion.

MedCité news: You say it’s real time, but nothing in healthcare is actually real time, right? It’s not like seeing your Uber Eats meal arrive in the car in real time. Healthcare uses this term loosely, correct me if I’m wrong, but what do you mean by real time, actually?

Maheshwari: Yeah. So I would say that the observation is very astute. The aspiration is to do it in real time, really in real time.

Let’s look at the process today for a simple outpatient example. At the end of the day or two days after meeting with the provider, the provider completes the documentation, but the information is already lost. Then, in batch mode, it is sent to the Clinical Documentation Improvement (CDI) team. If it is not complete, it returns to the service provider to complete it. Then, in batch mode, the message is passed to the coding team, and if they find any errors, they go back upstream and modify those errors. Then, in batch mode, it is passed to the claims team who cleans up the claims based on payer-specific rules. Then they send it in batches to a clearing house, which runs a series of checks, sends it to the payer who signs a series of checks. Happy case. Everything is going well and it takes two to three weeks.

In a bad case, it could take months. This is a case where something is returned because there was an administrative error or the payer did not have enough information to approve it immediately. Then the back and forth begins and it can go from the same cycle again to even more cycles. So that’s the current state and the reason for that current state is that there is a lack of transparency between payers and providers. They try to do it with guesswork.

What real-time transparency does is that it removes uncertainty. True transformation comes when you can ask these questions in real time at the point of care, which is what really matters when you can make the right decisions.

For example, a patient comes in for an MRI. Are they covered for this? This requires the provider to ask the payer the question. Then it requires the payer to understand what the benefits are, what the contract is with the particular provider, what the guideline is that the MRI is approved or not, and then gives a referral and at the same time specifies how much the provider is going to be paid and how much the patient’s liability is. This capability before the service even exists is what we are bringing to life with Optum Real.

A brain MRI with or without contrast does not show much variability. But someone comes in because they have a cut on their hand – we don’t know what will happen during the exam. They might have stitches. They can then be vaccinated against tetanus. They may receive extra support because they have diabetes and do not recover easily. The complexity of the matter could therefore be very different depending on who benefits from this reduction and not only that. Whether the cut is a three-centimeter cut or a five-centimeter cut will change how it is coded during the encounter. This variability can therefore be addressed today through capabilities, where an ambient tracing capability can trace the encounter in real time.

Now, if this happens, we can bring in capabilities to assess whether the documentation is complete and accurate. The example of three versus five centimeters. There you can say… “Hey, you forgot the length of the suture type and can you provide me with the length of the cut?” And as soon as the documentation is complete, I can code it independently. I can complete it independently and get the payer’s response in real time as to whether this claim or investigation is approved. We can answer: “How much is the patient responsible?” “, “how much would the provider be paid? “. Before the patient leaves the exam room, all of this is done and set up, making the three-week, four-week process that we discussed collapse down to the check-up.

MedCité news: So it seems very rosy to me because everything in healthcare is so slow. I understand that vendors use ambient technologies and that some ambient technologies have the ability to document and code. So providers can create that perfect score. I understand all of that, but I’m still not sure that vendors have the ability to completely understand what you need unless you clearly share your protocols with them, saying “okay, this is going to be paid for and this isn’t going to be paid for.”

Maheshwari: This is exactly why this solution is different from anything else. Everyone interested in reimbursement solutions and AI today is asking, “Can I create better AI for the provider?” And then the other side says, “Can I build a better AI for the payer” so that it can compete with the provider’s AI, right? So what was once a competition between rules-based systems is transforming into a competition for AI. We will find ourselves in the same place again.

The way to solve this problem is to create this transparency in real time. You’re right, payers have always been cautious – for lack of a good word – in terms of creating this full transparency, but what we have going for us is… Unitedhealthcare has opened up these APIs that will provide real-time transparency in these queries about the payer with a very high level of precision, not just saying “Puneet is eligible for this thing”, but at a level of specificity that says “Puneet is eligible for this thing against the specific diagnostic code that Puneet has for the benefit structure that he has for the contract that I have with his particular provider. This decision was missing in the past.

MedCité News: The insurance business model is simple, right? You are a for-profit entity and the way you make money is you pay less in claims than you bring in in premiums. Now, if you create a transparent system where you provide your protocols, you are, in a way, threatening your own business model. Isn’t it?

Maheshwari: So if you look at the statistics, the numbers tell a different story. When a provider submits a claim, 80% of them are approved and paid. About 10 to 20% are reworked. The majority of these reworks occur because the payer does not have enough information to pay the claim…and the provider has some level of problems in the claim or there are errors. [Note here that Maheshwari seems to imply that all errors/problems or lack of information in the claim lie necessarily on the provider side. I personally have been in situations where I fought my insurance company after they provided incorrect provider network information to me. I won only partial reimbursed from the payer even though the fault for providing wrong information lay completely with the payer. The payer in that case was not Unitedhealthcare, however.]

The final refusal rate that occurs for medical reasons is less than 10%. So all of those overheads that occur between payers and providers for first returns are completely eliminated with Optum Real. Now, I as the payer, and you as the provider, can always debate whether this was medically necessary or not. But this number of refusals is 2 to 3%. The rest corresponds to administrative costs.

But you can go even further. Even for the 80% refunded in 2 weeks, there is a $250 billion RCM industry on the provider side and there is about a $100 billion on the payer side when it comes to payment integrity. So the industry spends between $300 billion and $350 billion to get the provider paid for the service they provided for claims that fall into the 80% approved category. Now, if we create this transparent system in real time, you will get spectacular efficiency.

MedCité News: So is Optum Real trying to put these RCM and payment integrity industries out of business?

Maheshwari: Ending its activities is probably a much more ambitious and aggressive statement, I would say. I would definitely say that we owe it to ourselves as patients, payers and providers to reduce the administrative waste and administrative hurdles we encounter.

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Does this mean that the era of “delay and denial,” as insurance company tactics have been regularly described, is officially over? Allina Health, a health system based in Minnesota where UHG is also headquartered, has apparently realized significant savings using Optum Real, according to Optum’s press release.

As for providers in the rest of the country, only time will tell. We ask providers to contact us if your experience with Unitedhealthcare’s claims and reimbursement systems improves significantly with Optum Real. And in the meantime, we at MedCity News will keep it real.