UnitedHealthcare (UHC), one of the nation’s largest private health care insurers, has announced site of care prior authorization review for certain advanced computed tomography (CT), magnetic resonance (MR) and magnetic resonance angiography (MRA) outpatient imaging procedures. The policy, described on page 24 in the insurer’s October 2018 Provider Network Bulletin, will be effective January 1, 2019.
In Frequently Asked Questions posted October 4, 2018, UnitedHealthcare said the reviews aim at improving health care services, outcomes and overall cost of care.
Site of care prior authorization at UnitedHealthcare will apply to its commercial plans including UnitedHealthcare, Neighborhood Health Partnership and UnitedHealthcare of the River Valley and affiliated providers in all states except Iowa, Kentucky and Utah. The policy will branch from its current prior authorization process for medical necessity determination. The insurer will review site of care prior authorization for hospital outpatient services based on a new utilization review guideline.
For dates of services on or after January 1, 2019, UnitedHealthcare will review the site of care under terms of the member’s benefit plan after prior authorization is requested for specific advanced diagnostic imaging procedures as part of UnitedHealthcare’s prior authorization process. Sites of care reviews will be conducted only if the procedure will be performed in an outpatient hospital setting. They will not be performed if the procedure will be performed in a freestanding diagnostic radiology center or an office setting.
Here are some of the key takeaways from the insurer’s Q&A:
Q10. What if a patient has medical conditions requiring the use of an outpatient hospital setting?
A10. We understand some patients need more complex care because of factors like age or medical condition. We review every plan member’s situation to evaluate a site of care according to their needs. We’ll consider any information you provide that shows whether there’s a reason for a procedure to be performed in an outpatient hospital setting.
Q12. What happens if the nearest participating freestanding imaging center is a long distance for the plan member to travel or doesn’t have the equipment or resources for the planned procedure?
A12. We realize there may be instances when a plan members may not be close to a participating freestanding imaging center with the necessary resources for the care they need. In these cases, the procedure will be authorized at a network outpatient hospital facility.
Q13. How will the review process affect decisions between care providers and their patients?
A13. We support informed patient choice and respect care decisions between you and our plan members. Our coverage determinations reflect only whether or not a service is covered under a member’s benefit plan and aren’t intended to replace your treatment decisions.
ACR staff has reached out to UnitedHealthcare for additional information and is awaiting a response. Please address your questions to Kathryn Keysor, ACR senior director of economics and health policy at email@example.com.