Beginning Sept. 1, UnitedHealthcare began requiring prior authorization for physical therapy, occupational therapy, speech therapy and Medicare-covered chiropractic services delivered in multidisciplinary offices and outpatient hospital settings.
The requirements came as a surprise to many physical therapy specialists and patient advocates, who have already seen major delays in care and a lack of communication from the insurer.
Three specialists and members of the American Physical Therapy Association related toBecker's the headaches they have faced from the program so far.
"Following a member's initial consultation and evaluation, we are asking certain therapy providers to provide information to confirm that treatment plans are supported by appropriate clinical evidence and continue to align with the member's current health needs," a spokesperson for UnitedHealthcare told Becker's.
Question: Can you discuss any direct patient impacts you have seen from new prior authorization requirements since they were implemented?
Rick Gawenda, chair of the Payment Policy Committee of the Private Practice Section of the American Physical Therapy Association: As you go into the portal to opt in, the systems are down. You can't even get the information in, which is all opposite of traditional Medicare. Traditional Medicare does not require this, so patients are definitely being affected. Our private practice section represents a lot of small mom-and-pop practices. They can't afford to see patients and hope to get payer approval, because if you don't, you just lost all that money, and they just don't have that money in their bank account to be able to do that.
Michael Horsfield, president of the Private Practice Section of the American Physical Therapy Association and CEO of Rock Valley Physical Therapy (Moline, Ill.): This has been just a disaster as far as the rollout on Sept. 1. UHC said they would have the site up and going before that, but it wasn't up and the first glitches in the system are still there. I just talked to our billing office team, and I've gotten emails from many members across the country that wait times are anywhere from 60 minutes to three or four hours to talk to anyone. So some practices decided they're not going to see any Medicare patients with UHC until they get approval of the prior authorization.
Our company decided that we are not going to deny patients, we are going to keep seeing them. In the first 10 days, we had 151 patients submit prior authorizations, and of those we only got 36 of those back. So we have to make a decision whether we see those people and try and take the risk of not getting paid, or start denying care. We've had patients cry in our offices because of this. And then again, of those 36 that we had returned, half of those gave us the number of visits the therapist thought was required, which would never have happened under traditional Medicare. They reduced the number of visits. The first one that came through, we asked for 12 visits, we got four. And our experience is not unique, this is what we're hearing from everyone around the country.
Robert Hall, senior payment consultant at APTA Private Practice: I think looking at it from the practice level is really important. This burden is something that takes PTs away from their patients. It frustrates patients who want to continue the services that are medically necessary. There's an American Medical Association that went out in June of 2024 that says one out of four folks think there's a huge impact on patients from the prior authorization burden. APTA has a survey from 2023 that says 75% of PTs think that prior authorization delays medically necessary care. And when you think about PT, it's a lot of visits, right? It's not one surgery at a time. It's 12 visits. It's something that folks need to progress over time. So if you do that, it's very different than, you know, large surgeries or even primary care visits, right? PT, you're supposed to go a lot of times. If you get prior authorization burdens, it radiates out for PTs in a different way than it does for most providers. And you know, they're low-cost visits when it comes down to just the value proposition, so it makes no sense to me that you would want to limit how much PT people get. They are not costly appointments in comparison to much of the rest of the healthcare system, but it's still really important.
Q: Have you had the ability to work with UHC to discuss these new requirements and are they being communicative?
MH: The APTA has been really working on trying to get a contact, or communication our lobbyists met with our advocacy teams, met with their advocacy team last week, and that advocacy team, I think the communication was essentially, "I don't know why you're talking to us, we don't know what you're talking about. We'll put you in touch with somebody that will help." But there's been no progress that I know of there.
RH: I talked to this one person through another liaison, and it's just that clearly hasn't worked there. They're not listening, and they're not understanding our side of it. Advocating for patients is what PTs are doing here. And a lot of times, it's a Medicare population, it's not one that's going to be as vociferous as you know, a 30-year-old with these problems. So PTs feel it's their responsibility to be trying to get these folks what they need. It's like a black hole right now in communicating with them.
Q: UnitedHealthcare has recently implemented a gold card program for several other physician specialties. Would you be in favor of a gold card style program for PT?
RG: You know, obviously it's disappointing No. 1, to see that PTs are not eligible for the gold card program. Would I be open to it? Sure, but I think we would need to know the rules. And obviously, UHC is really not being forthright and transparent on how an organization becomes eligible for the gold card. They're not telling you that. It's just right now, you just log in and find out, are you in or are you out. So again, if the only way to get into a gold card is by limiting how often you treat a patient, and you're doing that so you can be in a gold card program to get away from prior authorization, but yet you're not serving your patients, right?
RH: I think the gold card plan is like putting lipstick on a pig, right? I mean, the idea that we're going to go back to prior authorization for this high-volume service of physical therapy and then say, "Oh, look what we've got to cover, because we've got a gold card program." It's a huge leap backwards. Last year, UHC said they weren't going to be doing prior authorizations. There are repercussions to unjustified change. I don't know what the justification is for this, right? I mean, why are they coming out and saying "We need to do this now."
Q: So you felt like prior authorization implementation came out of nowhere?
RG: Yes. The August UHC newsletter came out, and that's where the news came out. There was nothing on the website, no newsletter, no nothing. People, "got a letter in the mail" in July, but yet we have people that say they never got the letter, they never got the notification, etc. So [there's] a lot of confusion out there, you know, UHC, Medicare Advantage, and this prior authorization process, and then UHC, Optum health and the prior authorization process, and it's very confusing for people.