In August 2024, after UnitedHealthcare® (UHC) announced the prior-authorization requirement for its Medicare Advantage and AARP® Medicare Advantage plans, the Kentucky Association of Chiropractors and other chiropractic advocacy groups began extensive advocacy efforts:
- The Kentucky Association of Chiropractors (KAC) addressed the problem with UHC directly (see letter here),
- KAC launched a patient advocacy campaign, providing doctors with flyers calling patients to action (flyer), and
- KAC leveraged the power of ChiroCongress and coordinated advocacy efforts with state associations across the country.
Even with these significant efforts and the efforts of other national associations, UHC/Optum has opted to only slightly modify their prior authorization requirements for chiropractic, physical, occupational, and speech therapy services under UnitedHealthcare® (UHC) Medicare Advantage and AARP® Medicare Advantage plans (announcement).
The following changes will take effect on January 13, 2025.
Important Note: UHC uses two distinctly different phrases: 1) Prior Authorization Request – this is the action that continues to be required of providers. 2) Clinical Review – this is the action of UHC and only comes AFTER a Prior Authorization Request.
Key Highlights of the Policy Update
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- Prior Authorization Requirement Continues: Providers must continue to submit a prior authorization request for the entire plan of care, including the full duration and number of visits requested. Despite the perceived change, providers must still submit a prior authorization request and receive approval prior to bill submission.
- Initial Care Coverage Without Clinical Review: Up to six visits within the first eight weeks of a patient’s initial plan of care will be covered without requiring UHC to perform a clinical review of your Prior Authorization Request. This provision applies under the following scenarios:
- The patient is new to your office;
- The patient presents with a new condition; or
- The patient has experienced a gap in care of 90 or more days.
- Initial Consultation Exempt from Prior Authorization: The initial consultation or evaluation does not require prior authorization. This remains unchanged from the original requirement.
- Timeline for Authorization Requests: Providers have up to 10 business days after the initial consultation to submit authorization requests. Care may begin immediately following the initial consultation. This remains unchanged from the original requirement.
- Additional Visits or Extensions: Requests for visits beyond the initial six or exceeding the eight-week limit will require UHC to perform a clinical review of your Prior Authorization Request.
- Submission Processes: Providers must continue using the Optum Provider Portal for submissions and submit claims after receiving approved authorization. This remains unchanged from the original requirement.
Analysis
The Good – Chiropractors will know in advance that his or her “request qualifies for coverage of up to six (6) visits, over up to eight (8) weeks pending member eligibility and timely filing.” Thus, you can treat while waiting for approval (up to six visits within 8 weeks).
However, The Bad – UHC continues to require Chiropractors to perform prior authorization requests for their UHC Medicare Advantage and AARP® Medicare Advantage plans regardless of the number of visits and time requested. However, UHC will only clinically review the requests if they exceed six visits or 8 weeks. It is also important to note that if you ONLY request six visits over 8 weeks and the patient requires more visits, then another authorization will be required for the additional visits.
Recommended Action
The KAC is encouraging doctors to continue to submit the prior authorization requests for the full treatment plan that is necessary to bring a UHC patient back to health. With this change, you will be able to treat the patient (but not submit the claim form) before receiving the official prior authorization approval since “Your request qualifies for coverage of up to six (6) visits, over up to eight (8) weeks pending member eligibility and timely filing.”
