UnitedHealthcare has expanded prior authorization requirements and site of service medical necessity reviews for certain surgeries in an effort to shift surgical procedures to less expensive locations, according to Modern Healthcare.
The outpatient surgery policy will limit the circumstances under which UnitedHealthcare will pay for certain surgeries in a hospital outpatient setting.
Taking effect in November for fully insured groups in most states, UnitedHealthcare will only pay for a surgical procedure performed in an outpatient hospital setting if the insurer determines the site of service for the procedure is medically necessary, UnitedHealthcare told Becker's Hospital Review.
"Medical necessity reviews for site of service occur during our prior authorization process and are only conducted if the surgical procedure will be performed in an outpatient hospital setting," UnitedHealthcare said. "We utilize our Outpatient Surgical Procedures – Site of Service Utilization Review Guideline to help make our site of service medical necessity determinations. Site of service medical necessity reviews are currently being conducted for certain surgical procedures and will apply to additional surgical procedures beginning on Nov. 1, 2019 for most states."
In California, Colorado, Connecticut, New Jersey and New York, medical necessity reviews will begin for certain surgeries occurring on or after Dec. 1, according to a UnitedHealthcare bulletin. Site of service medical necessity reviews do not apply to providers in Alaska, Kentucky, Massachusetts, Maryland and Texas.
With the outpatient surgery policy, the insurer said it hopes to reduce healthcare spending by guiding patients toward ambulatory surgery centers, where care may be cheaper when there isn't a substantial medical reason for the surgery to be performed in a hospital outpatient setting.
More articles on healthcare finance:
4 reasons for medical coders to query a provider about documentation
Healthcare organizations name their top vendors
Health and well-being coaching codes approved: 4 things to know