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Legal Update - 12.2.15
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United Healthcare:

No new information here.


As always should you continue to have take backs from UHC you should appeal those decisions.



On November 24th we received a response from the Sixth Circuit Court of Appeals. The Court has requested that the Department of Justice, on behalf of the Department of Health and Human Services, file a letter brief with the Court stating its position on the three key issues in our appeal – federal officer removal jurisdiction, administrative exhaustion, and express preemption. The government’s brief is due no later than January 15, 2016. After it is filed, we will have seven days to file a responsive brief.


This is the second request for post-argument briefing from the Court. Our legal team says this is rather rare, since most cases are decided following oral argument without additional briefing. This indicates that the Court is taking our case very seriously and is getting as much input as possible prior to making a decision.


We will continue to update our membership as we gain more information.


If you are still having issues with Humana taking monies it is important that you appeal this decision.



Another call was held with OPTUM on November 20th. Nothing much changed but OPTUM is standing by their position that this transition is not as bad as we are making it out to be. They shared that there have been no rash of complaints or withdrawals from the network therefore we are over reacting to the change.  They said until we can provide them with real evidence of what we are claiming there is nothing they can do.


We pushed the following with them:

1.       They cannot cap the benefit and do the pre-authorizations.

a.       They claim that over 600 providers in Ohio will no longer need to do any paperwork for them in this new model.  There are only about 100 that will remain in tier two and this will not be that way for long.


2.       This will greatly reduce the reimbursement for a good portion of the providers in our state.

a.       They claim this is not true.  They said they have been doing this in other states for years and with PT’s even longer and it never results in the majority of the market getting paid less overall.  They did state that there would be a few that make less but they would argue those providers are over billing to begin with.


3.       This model will result in beneficiaries not getting the services they need and force them in to    

          more costly forms of care.

a.       They again said this has not been the case in other markets.


The bottom line is that they are not planning to budge on this new model.  The OSCA will continue to work with our legal team and other national groups to try and change this current model.


We need providers to keep track of their data as they get deeper in to the months. We need to be able to go back to OPTUM and show them this is not working on our end. Right now all we have is theories, we need hard numbers.  We encourage providers to keep track of the lost revenue and share that with the OSCA on a monthly basis.  You can send this information to 


We will provide further updates to our members as we continue this effort.

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