Changes to Optum's DME program

And potential implications therefrom.

Last week Optum announced it was changing its DME network; I asked Matt Wolfe to clarify Optum’s plans. Kudos to Matt for actually engaging and responding…far too many in this industry choose instead to avoid responding or are defensive when questioned about their business.

It’s kind of/pretty confusing - may be just me - but here’s my takeaways. (Matt’s response to my questions is below).

• Optum’s looking to leverage its massive buying power as a giant healthcare insurer; adding work comp, auto etc to the payers accessing its DME network is a financial margin move.

• As Matt notes below, this is “part of a multi-phase initiative”…I’d bet over time Optum WC & Auto customers will be shifted to other specialty providers/networks owned by/contracted with Optum. (factoid - Optum is the largest single employer of physicians in the country)

• I think DME providers who are contracted both directly with Optum and CareCentrix will find Optum chooses to reimburse based on whichever contract pays less. Matt didn’t say or imply that but that’s usually the way these things work.

• CareCentrix’ network has not been focused on or involved in WC/auto to date. And therein lies a potential issue. Workers’ comp is DIFFERENT.

  • Comp payers care about return to work, improving functionality, sustained recovery. Group health doesn’t.

  • State fee schedules are absurdly Byzantine and often quite different from group health contracts.

  • Documentation, notes, communication protocols and parties are central to the work comp care process - and tangential at best in the real world outside WC.

• Sure, some/many/most of CareCentrix’ already-contracted providers are familiar with work comp so this won’t be an issue. But most/many/some are not, and when they are not WC savvy they will be a giant pain in the ass for adjusters, case managers, employers and supervisors.

Optum Workers’ Comp and Auto No-Fault (“Optum”) reached an agreement in Q4 ‘25 with Optum Insight—another company within our enterprise—to bring key elements of their group‑health DME product, DME Navigator, into the workers’ comp, auto, and injury space. DME Navigator is a product offered through a partnership between Optum Insight and CareCentrix, but our agreement is with Optum Insight.

With this agreement, Optum is enhancing our DME network, which will allow us to offer an improved DME product. This is part of a multi‑phase initiative to improve our process, technology, network reach, and buying power so we can compete differently in this space. Most importantly, it will help us drive better outcomes and improve patient and client satisfaction.

This agreement does not shift all DME to CareCentrix’s network. Any DME provider in both the current Optum DME network and the DME Navigator network—with overlapping HCPCS items—will be informed of Optum’s move to the DME Navigator network.

Any DME provider currently in our Optum network that is not part of the DME Navigator network or is contracted with Optum for HCPCS not offered in DME Navigator, will be encouraged—but not required—to join the CareCentrix network. These providers will remain contracted in Optum’s direct DME network unless and until they choose to join CareCentrix. We will continue to manage our direct network and are not terminating any workers’ comp– or auto‑specific partnerships or capabilities. We have been and remain intentional about preserving the unique service needs of the work comp and injury industry.

We are not shifting any processing or support (client or injured person) to Optum Insight or CareCentrix. We are simply adding their network. Optum will continue to serve clients and injured persons exactly as we do today.

CareCentrix will continue to manage their network, including contracting and credentialing. Optum will continue to manage our direct DME network.

CareCentrix will become our primary DME network on 5/1; we are working with providers that are currently in both the CC network and our network to amend agreements (essentially ensuring we don’t have overlap at the provider + HCPCS level). We sent updated notifications to our providers yesterday to clarify what is changing. For those not in the CC network today, they are being invited to join, but choosing to abstain does not remove them from our Optum network or remove them from being eligible to receive referrals from Optum Workers Comp and Auto No-Fault.

This is one of a few initiatives underway as we transform to drive more value. With this, we’ve partnered across our enterprise to bring additional value to our clients and claimants by leveraging this network and components of what has been a very impactful product offering for health plan clients. For Optum Workers Comp and Auto No-Fault, this is going to simplify and modernize processes, add nearly 1,000 additional suppliers, and allow us to improve both quality, turnaround time, and our pricing to clients, all while helping produce better clinical outcomes.

What does this mean for you?

Headaches and perhaps lower reimbursement for service providers.

Payers and employers, make your voice heard if this is good or not for your injured workers.