UnitedHealthcare released the specific procedure codes it will exempt from prior authorization Sept. 1 as part of the insurer’s previous pledge to reduce requirements by 30% before the end of 2026.
The code lists cover 1,700 procedure codes for a range of services across commercial, Medicare Advantage, individual exchange and Medicaid plans. Effective Oct. 1, providers will no longer need to seek the insurer’s approval for many outpatient procedures, including lesion excisions, fracture treatments, joint injections, arthroscopies, colonoscopies, endoscopies, biopsies, hernia repairs and soft tissue tumor removals. Genetic and molecular testing codes also make up a large portion of the lists.
UHC will also drop site-of-service necessity reviews for certain endoscopy services and screening colonoscopies performed in outpatient hospital settings.
UHC has also pledged to eliminate two-thirds of pediatric prior authorization requirements by the end of 2026, and 70% of prior authorizations will be part of a new standardized submission process by year’s end.
However, physicians remain skeptical about whether the pledged 30% reduction will make a meaningful difference in the burdens and delays often associated with prior authorization. Two physicians recently joined Becker’s to discuss their reaction to UHC’s policy update and how they think it will shape their practice moving forward.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: Do you believe that UHC’s pledge to cut prior authorization by 30% will make a meaningful difference in the burden prior authorization places on physicians and their practices?
Vikas Patel, MD. Executive Vice Chair, Department of Orthopedic Surgery at University of Colorado Anschutz School of Medicine (Aurora): Sadly, this is just a ploy that will not really make a significant difference in our practice. Simply changing some of the procedures to “no authorization required” will not really help the process. They make the requirements for even basic procedures, quite onerous for the patients and the providers. This includes the need for failed physical therapy, failed multiple medications, failed activity, modifications, failed injections, etc. And then the diagnoses and imaging have to be perfect as well in order for a procedure to be considered appropriate. If the procedure is performed, and all of these criteria are not met, then the payment will be denied on the backend, and we will have no recourse. While it makes it easier for the procedure to be performed, it is equally onerous, if not harder to get paid.
Richard Novack Jr., MD. Ultimate Bariatrics (Plano, Texas): I do not believe that they’re promised to cut prior authorizations by 30%, will make any difference. Frankly, I don’t believe that they’re gonna cut their prior authorizations by 30%. I personally think they’re just trying to improve their public image with false statements and promises. Furthermore, even if they did cut their prior authorizations by 30%, it means absolutely nothing because they’ll just deny the claims on the back end. When we get a prior authorization in the fine print, it actually says this does not guarantee payment in any way. So why do I have to waste my time with prior authorization if they’re just gonna deny the claim anyway. It becomes so ridiculous. and now procedures we’ve done for decades are being called experimental, so that they don’t have to pay the claims even though the patient needs the procedure or has already had surgery and the insurance Company denies payment to us regardless. I have zero faith that UnitedHealthcare will ever act in good faith.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
