UnitedHealthcare (UHC), one of the largest private healthcare payers in the U.S., announced plans to eliminate prior authorization requirements later this year for a significant portion of the items it covers. While the change is consistent with similar moves made by UHC competitors, the notice is light on details.

Next Episode: Thursday, June 20, 2024

In March, UHC disclosed its intentions to eliminate prior authorization requirements for 20 percent of items currently subject to advance decision protocols. The company will implement the removals in the second half of 2023 for applicable items covered under its commercial, Medicaid, and Medicare Advantage policies. The announcement, however, did not detail specific products.

Medicare Advantage Plan Authorizations for DME

Insurance companies have substantial leeway with regards to their commercial policy practices, but we suspect this initiative is motivated in part by pressure on UHC and other payers to improve authorization practices for Medicare Advantage Plans, even if their inclusion in the announcement seems casual.

Prior authorization requirements are relatively new for DME with regards to the Medicare population. Suppliers have been, for the most part, pleased with Medicare’s prior authorization measures for fee-for-service (FFS) beneficiaries, finding them efficient vehicles for validating claims before delivering covered items to eligible beneficiaries.

Authorization practices required by Medicare Advantage Plans (MAPs), on the other hand, are a sore spot with suppliers and regulators alike. A 2018 OIG report found MAPs routinely denied prior authorization requests only to have 75 percent of those decisions overturned on appeal. In response, CMS published a final rule in April 2023 to substantively align MAP authorization practices with those used in the FFS program.

While we hope DME suppliers will benefit from reduced administrative burden, it is hard to estimate the impact of this change until UHC provides more details, namely, the specific products affected. In the meantime, we recommend suppliers monitor UHC authorization and claim responses carefully for any changes to current procedure.