Is Optum Real For Real?

During 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 that is designed to remove the friction between providers and payers when it comes to submitting claims and getting reimbursed in a timely manner.

The announcement is not a moment too soon, given that provider resentment against what they believe is a policy of “delay and deny” by insurers has reached a boiling point. Executives from the company took the stage at HLTH to explain how the vast majority of claims get processed quickly and it is just a few that gives people headaches. The reason for this: lack of transparency.

“If I have to summarize it in one word, I would say the biggest challenge in claims and reimbursement is guesswork,” said Puneet Maheshwari, senior vice president and general manager of Optum Real, to the audience on Tuesday. “The guesswork that happens on the provider side, the guesswork that happens on the payer side, leads to significant amounts 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] allows real-time data exchange between payers and providers, enabling the identification and interception of known issues at the point 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 following the panel discussion on stage, Maheshwari declared that Optum Real was designed to remove the data fragmentation that hobbles the claims adjustment process and can save the millions of dollars that providers pay clinical documentation improvement teams to increase their chances of getting reimburses and the millions of dollars that payers pay claims integration companies to make sure providers are doing everything by the book. Here’s a lightly edited Q&A of the discussion.

MedCity News: You are calling it real time, but nothing in healthcare is actually real time, right? It’s not like seeing your Uber Eats meal arriving in the car in real time. Healthcare uses that term loosely, correct me if I’m wrong, But what do you mean by real-time, actually?

Maheshwari: Yeah. So I would say the observation is very astute. The aspiration is to make it real-time, in earnest real-time.

Let’s look at the process today for a simple ambulatory example. By the end of the day or two days after the encounter with the provider, the provider completes the documentation, but by then information is already lost. Then, in batch mode, it gets sent to the clinical documentation improvement team (CDI). If it is not complete, then it goes back to the provider to get it completed. Then, in batch mode, it goes to the coding team, and if they find errors, they go upstream and change those errors. Then in batch mode it goes to the claims team that scrubs the claims based on payer-specific rules. Then they send it in batch mode to a clearing house, which run a set of checks, sends it to the payer who signs a set of checks. Happy case. Everything works out fine and it takes two to three weeks.

On a bad case, it can take months. That’s a case when something gets returned because there was an administrative error or the payer did not have enough information to approve it right away. Then the back and forth begins and that can take anywhere from the same cycle all over again to even more cycles. So that’s the current state and the reason for that current state is because there’s lack of transparency between payers and providers. They try to do it with guesswork.

What real-time transparency enables is that it removes the guesswork. Real transformation comes when you can ask these real-time queries in the moment of care that really matters when you can make the right decisions.

For example, a patient is walking in for an MRI. Are they covered for this? This requires the provider to ask the question to the payer. Then it requires the payer to understand what are the benefits, what are the contract with the particular provider, what is the guideline against which MRI is approved or not, and then give a referral and along with that give clarity around how much the provider is going to be paid and how much is the patient liability. That capability before the service even exists is what we are bringing to life with Optum Real.

A brain MRI with or without contrast doesn’t have a lot of variability. But somebody walks in because they have a cut in their hand – you don’t know what all will be done in the exam. They may get sutures. They may then get a tetanus shot. They may be given additional support because they’re diabetic and they don’t heal easily. So the complexity of the case could be very different depending on who is getting that cut and not just that. Whether the cut is a three-centimeter cut or a five-centimeter cut will change how it’s coded in the encounter. So that variability can be addressed with capabilities today, where an ambient scribing capability can scribe the encounter in real time.

Now if that happens, we can bring in and we are bringing in capabilities to assess whether the documentation is complete and accurate. The example of three versus five centimeters. Right there you can say … ‘hey, you forgot the length of the type of suture and can you provide me the length of the cut?’ And as soon as the documentation is complete, I can autonomously code it. I can autonomously fill it and get the response from the payer in real time on whether this claim or inquiry of the claim will get approved. We can answer, ‘how much is the patient liable?’, ‘how much would the provider get paid?’. Before the patient gets out of the exam room, all of this is done and teed up, making that three-week four-week process that we discussed collapsed down to the point of checkup.

MedCity News: So this seems super rosy to me because everything in healthcare is so slow. I understand that providers are using ambient technologies and some ambient technologies have the ability to document and code. So providers can create that perfect note. I get all of that, but I am still not sure that providers have the ability to completely understand what you need unless you share your protocols with them clearly, that ‘okay, this is going to get paid and this is not going to be.’

Maheshwari: That’s exactly why this solution is different than anything else. Everybody who’s looking at reimbursement solutions and AI today is saying, ‘Can I build a better AI for the provider?’ And then the other side is saying, ‘Can I build a better AI for the payer’ so that they can compete with the AI of the provider, right? So what used to be a competition between rule-based systems is turning into competition of AI. We’ll end up at the same place all over again.

The way to solve it is to create that real-time transparency. You’re right that the payers have historically been cagey — for lack of a good word — in terms of creating that full transparency, but what we have going for us is that … UnitedHealthcare has opened up these APIs that will provide real-time transparency into these queries on the payer at a very high level of precision of not just saying, ‘Puneet is eligible for this thing,” but to a level of specificity that says, ‘Puneet is eligible for this thing against the specific diagnosis code Puneet has for the benefit structure that he has for the contract that I have with his particular provider.’ That decision has been missing in the past.

MedCity News: The insurance business model is simple, right? You are a for-profit entity, and the way you make money is that you pay out fewer claims than you bring in as premiums. Now, if you create a transparent system where you are providing your protocols, then you are, in a way, threatening your own business model. Are you not?

Maheshwari: So if you look at the statistics, the numbers tell a different story. When a provider submits claims, 80% of them get approved and get paid. Roughly 10% to 20% get reworked. The majority of that rework happens because the payer doesn’t 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 was 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 denial rate that happens because of medical necessity is in the low single digits. So all this overhead that happens between payers and providers for those first time returns is getting completely eliminated with Optum Real. Now, I as the payer, and you, as the provider, can still debate whether this was medically necessary or not. But that number of denial is 2% to 3%. The remaining is administrative overhead.

But you can take it even a step further. Even for the 80% that gets reimbursed in 2 weeks, there’s a $250 billion RCM industry sitting on the provider side and there is roughly a $100 billion on the payer side in payment integrity. So the industry is spending anywhere from $300 billion – $350 billion so that the provider gets paid for the service that they have delivered for claims that fall in the approved 80% category. Now, if we create this real-time transparent system, you get dramatic efficiency.

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

Maheshwari: Putting out of business is probably a much more, I would say aspirational, aggressive statement. I would definitely say that we owe it to ourselves as patients, payers and providers to take down the administrative waste and administrative hurdles that we have.

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Does this mean the era of “delay and deny” — as the tactics of insurance companies have been routinely described — is officially over? Allina Health, a health system based in Minnesota where UHG is also headquartered has apparently seen great savings through Optum Real, according to the Optum’s news release.

As for providers in the rest of the country, only time will tell. We invite providers to reach out to us if your experience with UnitedHealthcare claims and reimbursement systems materially improves as a result of Optum Real. And in the meantime, we at MedCity News will be keeping it real.