UHC policy aims to limit hospital outpatient surgical procedures

October 31, 2019

Beginning Nov. 1, UnitedHealthcare is set to vastly expand a prior-authorization policy that aims to limit surgical procedures scheduled at hospital outpatient departments, according to a bulletin recently posted on the insurer’s website.

According to the bulletin, UHC will no longer pay for a vast array of surgeries performed at hospital outpatient departments unless the payer deems the site to be medically necessary for the procedure following a review.

In short, this is yet another major prior-authorization hurdle for providers and patients to navigate in an attempt to drive patients to lower-cost settings. It will affect more than 1,100 codes covering a variety of planned procedures, which include colonoscopies, eye surgeries, biopsies, tumor removals and insertions of a pace maker or heart catheter. 

The only states not affected by this expanded policy are Alaska, Kentucky, Massachusetts, Maryland and Texas. It applies to both fully-insured commercial groups and ACA exchange members.

Expect this change to have a significant impact on hospital revenue and to further limit patient choice. If you have questions about how this policy could affect your hospital, feel free to contact us at 517-486-4262.

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