The Second Wave of UnitedHealthcare's Prior Authorization Cuts Started in November
Client Alert
In August 2023, UnitedHealthcare released its plan to eliminate roughly one-fifth of its then-current prior authorization requirements. The first round of prior authorization cuts took effect on September 1, 2023. In that round, UnitedHealthcare eliminated the necessity for some prior authorizations for UnitedHealthcare Medicare Advantage, UnitedHealthcare commercial, UnitedHealthcare Oxford and UnitedHealthcare Individual Exchange plan members. The second and final round of prior authorization cuts began on November 1, 2023. The November 2023 Prior Authorization Cuts apply to the same plans as well as community plans (i.e., Medicaid managed care plans).
UnitedHealthcare’s Prior Authorization Cuts
The prior authorization cuts are part of UnitedHealthcare’s comprehensive effort to simplify the healthcare experience for members and providers. In sum, the cuts account for nearly 20% of UnitedHealthcare’s overall prior authorization volume.
The prior authorization process requires a patient to obtain approval from their health plan before proceeding with a medical service. The process results in barriers to timely care for patients, and is expensive, inefficient, and administratively burdensome for providers. Payers claim that providers do not always make appropriate, high-value healthcare decisions for their patients.
Starting November 1, 2023, some prior authorization codes procedures in cardiology, genetic testing, hysterectomy, spine surgery, radiology, arthroplasty, vein procedures and site of service sterilization were removed. Examples include:
- Spine surgery codes 22864 (removal disc arthroplasty anterior 1 interspace cervical), 22865 (removal disc arthroplasty anterior 1 interspace lumbar), and 0095T (removal total disc arthroscopy anterior approach, each additional interspace, cervical); and
- Cardiology codes 93303 (complete transthoracic echocardiography for congenital cardiac anomalies), 93304 (transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study), and 93306 (performing and interpreting of a complete transthoracic echocardiogram).
Prior Authorization Cuts Are Becoming a Trend
UnitedHealthcare is not the only payer that has announced prior authorization cuts this year. In August 2023, Cigna Healthcare removed roughly 25% of medical services from prior authorization requirements. This cut encompassed more than 600 codes, including roughly 100 surgical codes and 200 genetic testing codes, in addition to codes for durable medical equipment, prosthetics, and other services. Additionally, in September 2023, Blue Cross Blue Shield of Michigan announced that it was cutting approximately 20% of its prior authorization requirements and expanding its gold card program, which adjusts prior authorization requirements for providers with a track record of high-quality care and a high approval rating over six months or more.
In 2024, United Healthcare plans to implement a national gold card program for provider groups that meet eligibility requirements. Instead of adhering to the prior authorization process, qualifying providers in the program will follow a simplified notification process. UnitedHealthcare is set to publish informational guidance on this program before the end of the year.
If you have questions about the prior authorization process or UnitedHealthcare's prior authorization cuts, please contact your local BMD Healthcare Attorneys Daphne Kackloudis at dlkackloudis@bmdllc.com or Jordan Burdick at jaburdick@bmdllc.com.