UnitedHealthcare Announces Broad Prior Authorization Requirements for Therapy and Chiropractic Services Under Its Medicare Advantage Plans

September 9, 2024

In early August, UnitedHealthcare (UHC) announced it would require prior authorization for physical and occupational therapy, speech-language pathology, and chiropractic services provided in multidisciplinary offices and outpatient hospital settings effective September 1, 2024. Services provided in the home would not be subject to prior authorization. ASHA Advocacy is pushing back against this policy as we believe prior authorization is an ineffective utilization management technique that delays access to care for patients and increases administrative burden for clinicians.

What Speech-Language Pathologists Need to Know

Multidisciplinary practices are defined as settings where physical therapy, occupational therapy, speech therapy, and/or chiropractic care are all provided within a single facility or office.

Prior authorization is required for the following place of service codes:

• 11 Office
• 19 Off-Campus Outpatient Hospital
• 22 On-Campus Outpatient Hospital
• 24 Ambulatory Surgical Center
• 49 Independent Clinic
• 62 Comprehensive Outpatient Rehabilitation Facility.

This policy applies to UnitedHealthcare® Medicare Advantage plans nationally, including:

• Medicare Individual (including Chronic Special Needs Plans)
• Medicare Group Retiree
• UHCWest Medicare plans in Nevada, Oregon, Washington, and Texas
• UHCWest Medicare plans in Colorado (which will begin on January 1, 2025).

The policy does not apply to the following plans:

• UnitedHealthcare® Dual Complete Plans
• UnitedHealthcare® Nursing Home and UnitedHealthcare® Assisted Living Plans
• Erickson Advantage
• Preferred Care Network and Preferred Care Partners of Florida
• UHCWest (California, Arizona)
• OptumCare
• WellMed
• Peoples Health Plan
• Rocky Mountain Medicare Advantage Plans.

UHC notes that current prior authorization requirements in Arkansas, Georgia, South Carolina, and New Jersey for outpatient therapies continue as previously deployed and will now include Medicare-covered chiropractic services.

The policy requires providers to submit a prior authorization request after completing the initial evaluation but before delivering services outlined in the plan of care. Because the policy has just gone into effect, ASHA does not have data on how the policy is working. However, previous experience with UHC prior authorization processes indicates that requests are approved within three to 10 business days, and there's no clear pattern in terms of number of visits approved. For example, the number of visits approved does not appear to be tied to diagnosis, so it's hard to gauge how many visits might be approved.

How to Submit a Prior Authorization Request

Health care providers must submit the initial evaluation results and the plan of care (including the number of requested visits) by completing an outpatient assessment form. If additional visits are needed after the initial treatment plan is completed, health care providers will need to submit an additional prior authorization request. Full details on how to log in to the UHC website and submit a request (including a link to the prior authorization request form) are found in the announcement.

UHC notes it will review prior authorization requests for medical necessity using the criteria outlined in Chapter 15 of the Medicare Benefit Policy Manual [PDF], applicable local coverage determinations, and InterQual criteria. Medical necessity reviews are conducted by licensed medical professionals, including physical therapists, occupational therapists, and speech-language pathologists. The provider and patient will be notified of UHC's medical necessity determination.

What ASHA Is Doing

ASHA is meeting with UHC officials to understand the rationale for the policy and to ask for reconsideration. At a minimum, we are asking UHC to delay implementation and narrow the scope of services subject to prior authorization.

Both federal agencies such as the Government Accountability Office and nonpartisan organizations such as the Kaiser Family Foundation have found that prior authorization is an ineffective utilization management technique that inappropriately and unnecessarily delays access to care for patients and increases administrative burden for clinicians. As a result, ASHA has banded together with other therapy organizations to send a joint letter to UHC encouraging it to retract the policy immediately.

Questions?

Email ASHA's health care and education policy team at [email protected].