I spend a lot of time thinking about and fighting for access to good healthcare, particularly mental health and substance use treatment. I’m going to try to get into a routine of sharing some of the day to day barriers that we face as providers and as patients because we’ve normalized a capitalist system that nickels and dimes all of us literally to death while the insurance companies, their administrators, and their shareholders (HOW IS THIS EVEN A THING?) get rich.

Many of my posts will be specific to United/Optum. The issues are not unique to this insurer, but they have a near-monopoly on the Medicaid market here in RI. Which means our state pays them with our tax dollars to take some of those dollars and then decide whether the people actually doing healthcare work should get some of them too. It also means that for a community organization like mine, they get to control almost 80% of our revenue.

We’re kicking off this series with the despicable process known as ‘clawbacks’. The Managed Care Industrial Complex doesn’t call it this; I’m sure they have a very fancy name for their pattern of paying a provider for a service rendered, then deciding that we didn’t actually deserve that payment and taking it back. Occasionally, they are correct - perhaps the person lost eligibility and the claim should have denied to begin with. But by the time they come back for the money it is often too late for the provider to resubmit a claim to an alternative payer. So despite having provided a service and paying our providers for doing it, the organization is out of luck.

Many times, they are not correct and we do not owe them money. When this happens, someone from the organization must spend hours collecting the evidence that they are incorrect, demonstrating WHY they are incorrect, and submitting to them all of this documentation so they can ‘open a project’ to correct the incorrect clawback. Sometimes they have already taken back the payment from other payments, so the provider once again is shorted in cash flow.

It’s Quarter 1 of a new year, so over the last 2-3 weeks my organization alone has received at least 75 clawback letters. Each has to be investigated and addressed, one at a time, to see which ones we need to fight. I could be developing new programs, expanding our capacity to meet the unending demand for services, or helping build the workforce which has been decimated over the last decade. But instead, today I will open the latest stack of love letters from Optum and try to protect the money we earned by delivering a service we are contracted for. Stay tuned, there is something new to talk about every day.

The CEO of Optum earned $23.5 million dollars in 2023.