UnitedHealthcare's prior authorization removals just 'payer antics,' surgeons say

Orthopedic

Nov. 1 marks a new wave of prior authorization code eliminations from UnitedHealthcare, which announced plans to drop prior authorization requirements by 20% in August. 

On Sept. 1, the payer began phase one of its two-phased approach to eliminating prior authorization requirements for several procedure codes, accounting for 20% of its overall volume. 

During stage one, codes were eliminated for UnitedHealthcare Medicare Advantage, UnitedHealthcare commercial, UnitedHealthcare Oxford and UnitedHealthcare Individual Exchange plans.

As of Nov. 1, codes will be eliminated for UnitedHealthcare Community Plan holders as well. Four spinal surgery codes and three orthopedic surgery codes were cut from prior authorization requirements, but so far, surgeons have not seen any real benefit from the removals. 

In fact, the codes that were removed are some of the least utilized in musculoskeletal care. Now, surgeons are accusing UHC of removing codes for show, knowing they will have no real positive impact on patients or the industry. 

Two surgeons told Becker's the changes they are, or rather, are not seeing from the code removals. 

Adam Bruggeman, MD. Orthopedic Surgeon at Texas Spine Care Center (San Antonio): The codes that were eliminated are some of the least utilized codes. I'm not sure I have billed any of those codes in the last 10 years, or perhaps have only done so a handful of times. It would be interesting to see the frequency with which the eliminated codes were billed across the U.S. and what percentage of cases these codes represent for prior authorization as a percentage of all codes that require prior authorization. We continue to advocate for true reform, including finalizing the proposed rules and gold card-style legislative efforts at the state and federal levels.   

Brian Gantwerker, MD. Neurosurgeon at the Craniospinal Center of Los Angeles: I have not seen any changes regarding prior authorization elimination. If anything, I imagine it is a ploy to try to muddy the waters. Hospitals and physicians have experienced terrible amounts of denials and unfair withholding of payments and clawbacks. I imagine that there is a new, more  sinister technique that they will use in order to get around the prior authorization bills coming through Congress, and this is just a poorly spirited attempt. The next phase of payer antics I've seen is prepayment reviews, which technically get around the prior authorization process by having physicians perform the service after getting prior authorization, but then denying payment after the service has been completed. This obviously provides some window to get around privatization laws and "be compliant." Until the Office of Inspector General and the Federal Trade Commission enforce existing laws around insurance companies, we will never see improvement.

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