Resources

Client Alerts, News Articles, Blog Posts, & Multimedia

Everything you need to know about BMD and the industry.

The Second Wave of UnitedHealthcare's Prior Authorization Cuts Started in November

Client Alert
December 11, 2023

In August 2023, UnitedHealthcare released its plan to eliminate roughly one-fifth of its then-current prior authorization requirements. The first round of prior authorization cuts took effect on September 1, 2023. In that round, UnitedHealthcare eliminated the necessity for some prior authorizations for UnitedHealthcare Medicare Advantage, UnitedHealthcare commercial, UnitedHealthcare Oxford and UnitedHealthcare Individual Exchange plan members. The second and final round of prior authorization cuts began on November 1, 2023. The November 2023 Prior Authorization Cuts apply to the same plans as well as community plans (i.e., Medicaid managed care plans).

UnitedHealthcare’s Prior Authorization Cuts

The prior authorization cuts are part of UnitedHealthcare’s comprehensive effort to simplify the healthcare experience for members and providers. In sum, the cuts account for nearly 20% of UnitedHealthcare’s overall prior authorization volume.

The prior authorization process requires a patient to obtain approval from their health plan before proceeding with a medical service. The process results in barriers to timely care for patients, and is expensive, inefficient, and administratively burdensome for providers. Payers claim that providers do not always make appropriate, high-value healthcare decisions for their patients.

Starting November 1, 2023, some prior authorization codes procedures in cardiology, genetic testing, hysterectomy, spine surgery, radiology, arthroplasty, vein procedures and site of service sterilization were removed. Examples include:

  • Spine surgery codes 22864 (removal disc arthroplasty anterior 1 interspace cervical), 22865 (removal disc arthroplasty anterior 1 interspace lumbar), and 0095T (removal total disc arthroscopy anterior approach, each additional interspace, cervical); and
  • Cardiology codes 93303 (complete transthoracic echocardiography for congenital cardiac anomalies), 93304 (transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study), and 93306 (performing and interpreting of a complete transthoracic echocardiogram). 

Prior Authorization Cuts Are Becoming a Trend

UnitedHealthcare is not the only payer that has announced prior authorization cuts this year. In August 2023, Cigna Healthcare removed roughly 25% of medical services from prior authorization requirements. This cut encompassed more than 600 codes, including roughly 100 surgical codes and 200 genetic testing codes, in addition to codes for durable medical equipment, prosthetics, and other services. Additionally, in September 2023, Blue Cross Blue Shield of Michigan announced that it was cutting approximately 20% of its prior authorization requirements and expanding its gold card program, which adjusts prior authorization requirements for providers with a track record of high-quality care and a high approval rating over six months or more.

In 2024, United Healthcare plans to implement a national gold card program for provider groups that meet eligibility requirements. Instead of adhering to the prior authorization process, qualifying providers in the program will follow a simplified notification process. UnitedHealthcare is set to publish informational guidance on this program before the end of the year.

If you have questions about the prior authorization process or UnitedHealthcare's prior authorization cuts, please contact your local BMD Healthcare Attorneys Daphne Kackloudis at dlkackloudis@bmdllc.com or Jordan Burdick at jaburdick@bmdllc.com.

Health LawHealthcareHealth InsuranceDaphne KackloudisJordan Burdick
Client Alert

Corporate Transparency Act Effective Again

February 20, 2025The federal judiciary has issued multiple rulings on the enforceability of the Corporate Transparency Act (CTA), which took effect on January 1, 2024. Previously, enforcement was halted nationwide due to litigation in Smith v. U.S. Department of the Treasury. However, on February 18th, the court lifted the stay, reinstating the CTA’s reporting requirements. Non-exempt entities now have until March 21, 2025, to comply. Businesses should act promptly to avoid civil penalties of $591 per day and potential criminal liability.Client Alert

Status Update: Physician Noncompete Agreements in Ohio

February 11, 2025Noncompete agreements remain enforceable in Ohio if they meet specific legal requirements. While the AMA and FTC have challenged these restrictions, courts continue to uphold reasonable noncompete provisions for physicians. Recent cases, like MetroHealth System v. Khandelwal, highlight how courts may modify overly restrictive agreements to balance employer interests with patient care. With ongoing legal challenges to the FTC’s proposed ban, Ohio physicians should consult a healthcare attorney before signing or challenging a noncompete agreement.Client Alert

Immigration Orders and Their Economic Impact on Small Business: Insights from Attorney and Former Immigration Judge Rob Ratliff

January 30, 2025President Trump's recent executive orders, targeting immigration policies, could significantly impact small businesses in Ohio, particularly those owned by undocumented immigrants. With stricter visa vetting, halted refugee admissions, and potential deportations, these businesses face uncertainty, workforce disruption, and closures. Ohio's immigrant-owned businesses, especially in food services and transportation, contribute billions to the state economy, and any disruption could result in economic ripple effects.Client Alert

Corporate Transparency Act Ruling from the U.S. Supreme Court

January 24, 2025The U.S. Supreme Court recently ruled on the enforceability of the Corporate Transparency Act (CTA), lifting an injunction previously imposed by the Fifth Circuit. However, a separate nationwide injunction remains in effect, meaning businesses are still not required to comply with the CTA’s reporting requirements. FinCEN continues to accept voluntary reporting while enforcement remains paused.Client Alert

Lead Paint Contamination and Resources for Ohio Landlords

January 20, 2025Children are exposed to lead-based paint, which was used in most homes until it was banned in the US in 1978 and “can severely damage the brain and central nervous system causing coma, convulsions and even death.” Property owners and landlords should educate themselves on regulations and resources to mitigate their own liability.
Older posts