UM decision-making is based only on appropriateness of care and service and existence of coverage. Optum Care Network doesn’t specifically reward practitioners or other individuals for issuing denials of coverage or care. Financial incentives for UM decision-makers don’t encourage decisions that result in underutilization. Practitioners aren’t prohibited from advocating on behalf of the member and are advised of the following:
- The expectation to educate members regarding health needs
- To share findings of medical history and physical exams
- To discuss potential treatment options (including those that may be
self-administered) and the risks, benefits and consequences of treatment or
- The side effects and management of symptoms (without regard to plan coverage)
Recognize that the member has the right to receive sufficient information, to be able to provide input into the proposed treatment plan and has the final say in the course of action to take among clinically acceptable choices. Practitioners are ensured independence and impartiality in making referral decisions that will not influence: [29 CFR § 2590.715-219(b)(2)(ii)(D)]. This statement is also distributed to providers along with the affirmative statement above.
- Any other similar matters