If you have been following industry publications, such as the XiFin Beyond Billing blog or Billing Beat newsletter, you have been seeing a lot of activity from UnitedHealthcare (UHC) in the past year. As the largest commercial payor in the U.S., it is essential providers remain up to date on UnitedHealthcare’s policies to ensure any potential impact to revenue is proactively addressed. This blog provides an overview of three recent UnitedHealthcare policy changes and key strategies for providers impacted by these changes to maintain their financial stability.
The Good: Prior Authorization Process Changes
UnitedHealthcare has announced it is working to cut Prior Authorizations by 20%. During Q3 of 2023, UnitedHealthcare plans to launch an initiative that will eliminate prior authorization for common tests and treatments. Eliminating the need for the cumbersome process of applying for a prior authorization will help to speed up the time to treat for patients and allow providers to perform necessary tests for patients more quickly and with less administrative burden on the front end.
In 2024, UnitedHealthcare will launch its Gold Card program, which will award provider groups who consistently have high approval levels on prior authorization requests. It is similar in intent to a bipartisan bill that’s been introduced into the U.S. House of Representatives. In October 2022, UnitedHealthcare launched a similar program in Texas as a result of the Texas House Bill 3459, also known as the “Texas gold card exemptions.” According to the UHC Texas Gold Card Exemptions FAQs providers who submit at least five pre-authorizations requests for services and have a 90% approval rate on all pre-authorization requests will be exempt from requesting pre-authorizations on those services. The approval rate for providers is reviewed every six months.
Keep in mind that obtaining a prior authorization (or bypassing the strenuous process under the Gold Card Program that’s coming in 2024) does not eliminate the possibility of medical records requests prior to payment. UnitedHealthcare may still require that you provide documentation to support the services billed. If your approval rate for a service is below the 90% threshold, you must keep submitting pre-authorization requests for that service.
Also, remember that UHC is moving to non-paper correspondence. Last year, the organization announced that Prior Authorization and Clinical Decision letters would be found in the portal or via Application Programming Interface (API) for the West region. This represents a shift in how billing teams will need to organize their workflow to ensure that correspondence is reviewed and dealt with timely.
KEY STRATEGIES
Track tests requiring prior authorizations. Monitor UHC’s developments in eliminating tests that require Prior Authorizations or changes to the process, to ensure you are not spending unnecessary administrative time as the demands are lessened. Tests that require prior authorization change frequently and differ by payor plan so it is important to monitor information related to all UnitedHealthcare plans.
Ensure request are completed accurately. Ensure that Prior Authorization requests are complete and accurate for maximum success in solidifying your enrollment in the Gold Card Program and reducing front end burden related to obtaining prior authorizations.
Respond to medical record requests timely. Monitor medical record requests and ensure they are responded to in a timely fashion. Consider automating portions of your appeals process to minimize the time to collect.
Monitor portals. Establish processes in your billing department that ensure UHC correspondence is monitored closely in its portal to avoid missing critical items that could prevent payment.
The Bad: Pre-Payment Audits
UnitedHealthcare has partnered with Optum to install pre-payment audits related to multiple policies that indicate frequent over-utilization. Pre-payment audits can wreak havoc on a healthcare provider’s practice, creating cash flow shortfalls and other interruptions that negatively impact their business.
Providers can expect to see more CO-252 denials, indicating that additional documentation is required to adjudicate the claim. An appeal with the requested medical records is the appropriate next step in these instances. However, our experience indicates that success rates on those appeals may vary drastically.
KEY STRATEGIES
Review your coding. Ensure that codes are not stacked when they should be bundled or billed as a panel.
Review your ordering platforms. Analyze paper and electronic ordering platforms to ensure that they don’t require or influence an ordering provider to order a complete panel instead of individual tests, and that they do not encourage the ordering of more complex services than may be necessary.
Appeal CO-252 with appropriate documentation. Pay close attention to the CO-252 denials you are receiving, and the type of documentation being sent. As you work with UHC on this issue, it will be important to have consistent evidence that the testing billed was performed and medically necessary.
Contact UHC. Have your Market Access/Managed Care reach out to the higher-level contacts you have at UHC to begin discussions about the challenges you are experiencing, specific to your business and your testing. Connecting with the correct person could take some time, so initiate these conversations as soon as you recognize the issue.
IMPORTANT NOTE: Once you have the appropriate person engaged, it will be important to have an expert coder who is familiar with your ordering platforms, testing, locations, and code assignment who can interact with the UHC team.
Review paper correspondence. You may be getting paper correspondence via U.S. mail after receiving the CO-252 denial that contains additional information. It is important that you carefully review this documentation for additional details that can help in your discussions with UHC and your formulation of appropriate processes for working through the denials.
- Some of these paper correspondence items may require that you provide the ordering physician’s medical records to fully support the services billed.
- Use reporting to identify volumes of CO-252 denials by ordering physician and educate the ordering physicians on UHC’s policy and what is being required of you for payment.
- Point your ordering physicians to a portal, like the XiFin Client Portal, that allows them to upload their medical records securely to help streamline the work they will do in supporting your team.
- The paper correspondence may expose patterns in UHC’s denial of your claims. As patterns emerge:
- Review your coding and documentation practices related to those services,
- Craft documentation about your testing that can be used to support the services rendered and can be attached to appeals, and
- Communicate with your UHC contact regarding your findings and documentation.
The Challenging: Use of DEX Z-CodesTM for Molecular testing
Beginning on August 1 of this year, UHC will be migrating to the use of Z-Codes to identify the testing being billed on both professional and facility claims. The August 1 date applies to an initial list of codes published by UHC as “Wave 1.” Remaining tests will be added to this process in future waves.
For laboratories that already have a Z-Code for tests from this list being performed, you will simply update your billing system to send that Z-Code on your UHC claims. Z-Codes are currently required by four of the seven Medicare Administrative Contractors (MACs). However, for laboratories that are not currently required to utilize Z-Codes on their Medicare claims, there is an enrollment process for obtaining a Z-Code that must be completed prior to using the code for billing to UHC.
The implementation of a Z-Code for molecular tests could help UHC clearly identify and reimburse the test being performed. However, it is important to acknowledge that this development may impose a significant burden on healthcare providers. United Healthcare is encouraging providers to enroll and submit tests as soon as possible to allow time to identify and fix possible errors with test submissions. The current turn-around time for most MolDx program technical assessment registration is two to three months from original submission to receiving an initial response. If additional information is needed, the 2-to-3-month time span starts over again and continues to reset every time a provider has to submit further clarification.
KEY STEPS FOR SUCCESS
- Register. Register with the DEX™ Diagnostic Exchange Registry here.
- Apply. Apply for a Z-Code for tests you perform that are on the Wave 1 list. Remember that additional tests will be added later.
- Initial review may take up to 2 weeks. However, if additional documentation is needed, the process could be delayed.
- The email with the approval and related details may take up to 60 days.
- Only after receiving the email notification, can you begin to utilize the Z-Code on your claims.
- Update. Update your billing system to apply the assigned Z-Code to claims for your applicable tests.
- Monitor. UnitedHealthcare will deny claims without the appropriate Z-Code, so it is important to continue to monitor tests to ensure accurate payment.
Managing the constant fluctuations in payor policies can indeed be a challenging task. However, by embracing automation, enhancing reporting capabilities, assembling proficient teams, and allocating sufficient resources, these challenges can be effectively addressed. Collaboration with a reliable billing provider can greatly assist in navigating through these changes. By partnering with a knowledgeable and experienced billing provider, you can benefit from expertise and stay ahead of evolving payor policies. Working together, you can effectively navigate the complexities of payor policies and streamline your billing processes.
Contact us to learn more about XiFin’s comprehensive accounts receivable and financial management solutions that use a financial framework designed specifically to address the problems that undermine the effectiveness and efficiency of laboratories’ revenue cycle management. Stay informed with the latest updates by signing up for XiFin Beyond Billing blog alerts and receive up-to-date information directly to your inbox.
Additional Resources:
For more information of prior authorizations, check out our recently published blog,
4 Steps to Optimize the Prior Authorization Process.