You Won a UHC PA Policy Change
In the fall of 2024, UnitedHealthcare (UHC) implemented a prior authorization requirement for outpatient physical, occupational, and speech therapy, for Medicare Advantage members. The policy mandated that providers who continued to contract with UHC obtain approval before initiating treatment, leading to repeated delays in payment for medically necessary covered services and worse patient outcomes. APTA, APTA Private Practice and AOPT worked with other professional society advocates to spur this modification. Integrating work on Capitol Hill, with regulatory agencies and with direct pressure through meetings with the payer, your membership dollars led to this change.
And while the response from UHC was in no way perfect, we did move the ball. Under the updated guidelines, the initial consultation still does not require prior authorization. Additionally, up to six visits within the first eight weeks of a member's initial plan of care are now covered without a clinical review, provided one of the following conditions is met:
- The member is new to the provider's office.
- The member presents with a new condition.
- The member has had a gap in care of 90 or more days.
Plans of care requesting more than six visits or extending beyond eight weeks will still undergo a “medical necessity assessment.” Physical therapists are “encouraged” to submit prior authorization requests for the entire plan of care, including the total duration and number of visits. Authorization requests can be submitted up to 10 business days after the initial consultation, allowing treatment to commence immediately.
Professional organizations, including APTA, have acknowledged this policy revision as a positive development toward reducing administrative burdens and improving timely access to care. However, we will never stop advocating to eliminate barriers that hinder patients from accessing the medically necessary therapy services that are covered by the terms of their plan.