UHC, Optum Tighten Prior Auth Rules for Follow-Up PT Visits Under Many MA Plans

In a disappointing move that walks back needed reforms to burdensome prior authorization policies announced in August 2023, UnitedHealthcare is expanding prior authorization requirements within certain plans for follow-up PT visits when services are provided in office and outpatient hospital settings, effective Sept. 1. See which plans are impacted and which are excluded.

Some relief may be available to physical therapy practices that qualify for UHC's new Gold Card program. Slated to begin Oct. 1, the program recognizes practices that meet stated criteria indicating they consistently adhere to evidence-based guidelines. Gold Card providers will not need prior authorization for certain services identified by UHC, including some follow-up visits. See Page 2 of the Gold Card Program protocol description for eligibility information.

In a similar move, beginning Sept. 1, UHC's Optum Healthcare Solutions will require submission of a patient summary form for prior authorization of treatment visits following an initial evaluation for certain UnitedHealthcare and AARP Medicare Advantage plan members. The announcement of this program expansion was not posted in a provider newsletter; Optum mailed a letter to affected providers in July with a contact phone number of 800-873-4575 for questions. Updated plan summaries can be found at myoptumhealthphysicalhealth.com. Of note: Tier 1A, Tier 1, and Tier 2 providers will not be exempt from this requirement.

Under both programs, initial evaluations continue to be covered without the need for prior authorization. However, prior authorization must be requested if follow-up visits are required, whether the patient is new to therapy or currently receiving services.

APTA has contacted UHC to urge the insurer to reconsider its decision. The association also requested clarifications and has received some responses:

• UHC is not posting an official written policy change at this time; it directs providers to the announcement if they want guidance.
• The place-of-service codes being impacted are Outpatient (11 - Office), On-campus Outpatient (22 - Outpatient), Outpatient (24 - Outpatient Facility), Outpatient (19 - Outpatient off-campus), Independent Clinic (49 - Outpatient), and Comprehensive Outpatient Rehab Facility (62 - Outpatient).
• Out-of-network providers will not be required to submit a request for prior authorization for follow-up visits.
• Physical therapist services performed in a skilled nursing facility under Part B are subject to the new requirement.
• APTA is awaiting a response from UHC to clarify if home care services (place-of-service code 12) billed under the patient's Part B benefit will be excluded from the prior auth requirement.

APTA continues to work with colleagues from other affected health care disciplines in mounting advocacy efforts against this burdensome new policy and will inform members with any updates.

Meanwhile, UHC provides additional information in its announcement Prior Authorization Changes for Outpatient Therapy Services and on a related webpage. For specific questions, contact UHC at 888-676-7768 or Optum at 800-873-4575. UHC encourages providers to voice concerns via either Optum's online portal or email at [email protected].