Stakeholders seek details on UHC plan to eliminate some prior auths

WASHINGTON – UnitedHealthcare’s plan to reduce prior authorizations was met with skepticism by industry stakeholders who say it’s more likely a public relations move in response to increased government scrutiny. 

In August, UnitedHealthcare said it would begin a two-phased approach to eliminating prior authorizations for many product codes starting Sept. 1, 2023. That’s after the Senate Homeland Security and Government Affairs Committee in May held a hearing on denials and delays in Medicare Advantage; and an Office of Inspector General published a report in July on high rates of prior auth denials in Medicaid managed care. 

“The biggest black eye those plans have had is they are denying coverage that would be covered under the fee-for-service program,” says Laura Williard, vice president of payer relations for AAHomecare. “But what happens then is, it pushes the weight of the decision onto the provider’s back to take the risk (of providing equipment), knowing there’s an 80% to 90% chance, in some cases, that they won’t be paid on the back end.” 

Stakeholders had already raised concerns over high denial rates for non-invasive ventilators - even with prior authorization requirements in place from some major plans, including UHC. 

Removing codes completely from the prior auth list opens the door to further denials, says Craig Douglas, vice president of payer relations for VGM & Associates. 

“We’re already seeing higher than average denial rates for both claims and on prior auths from UHC specifically,” he said. “So definitely, there’s some red flags being raised from providers in those higher-end categories.” 

While the list of approximately 400 codes to be removed varies among UHC’s different types of plans – MA, commercial and Medicaid – Douglas estimates that about 50 codes pertain to complex rehab. 

“You’re talking about a potentially $20,000, $30,000 or $40,000 wheelchair not having an insurance company approve it prior to it to being provided,” he said. “It leaves the provider and the patient both guessing if it’s covered. The provider can’t eat the cost and the patient can’t pay.”  

AAHomecare planned to meet with executive leadership at UHC to seek clarification on several points, including their reasoning for which codes are being excluded and why it varies by plan, says Williard. 

“All the lists are all different and we want some understanding of how and why they developed the lists,” she said. “It makes it difficult for providers to know what’s included and creates a lot of inconsistencies and room for error for everyone.”