UnitedHealth Group/Optum Health updates

Attention NYSCA Members,

As many of you have heard, UnitedHealth Group / Optum has been implementing a 'per diem' capitated reimbursement methodology for many of it's health plans as it relates to chiropractic services in various states throughout the country. They have already done so with physical therapists. A Per Diem model of reimbursement typically provides for a maximum reimbursement level for all covered services rendered on a specific date. Although this change is somewhat consistent with the national trend away from traditional fee for service models and towards pay for performance, we have concerns as to how this change might be implemented in New York. We also understand that you, our members, have trepidations and questions as well. We appreciate you sharing those with us.

Optum staff has assured us that there is no reduction in the total amount paid for chiropractic care. As such, the per diem allowance may be higher than some providers are currently receiving, while lower for others. The NYSCA has concerns regarding the described change in payment policy and how it will impact the practice of chiropractic in New York. We wanted you to know that we are taking the opportunity to advocate for both our membership as well as the patients we serve.

The NYSCA Insurance Committee was invited to listen at a forum hosted by Optum, where several speakers presented information on the reimbursement modification. We were able to write in questions; however, time did not permit for the inclusion of all questions nor detailed answers. Based upon that presentation the NYSCA has placed our concerns in writing, which was recently sent to appropriate staff at UnitedHealth Group and Optum. 

The main issues include:

  • The timeframe for when this change will occur 
  • The reporting and reimbursement impact to participating and non-participating providers (as well as 'Tier' level) 
  • The inclusion of diagnostic services in the per diem allowance (such as radiology and electro-diagnostic testing) 
  • The potential for negative impact on patient care, especially for more complex cases 
  • Remaining consistent with the current laws of New York, including the chiropractic equality bill 
  • What programs UnitedHealth and Optum are considering and will implement consistent with the other tenants of pay for performance models, including incentives when 'best practices' are being utilized

The NYSCA Insurance Committee wants you to be aware of this change, as it will be coming to NY as it has in other states. We are working to get more details regarding this shift in payment policy and will continue advocating for you and your patients. Please keep an eye out for future releases.


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