June 21, 2019
Area(s) of Interest: Orthopaedic Surgery Payor Issues and Reimbursement Practice Management
Effective September 3, 2019, UnitedHealthcare (UHC) will require prior authorization for certain musculoskeletal surgical procedures when performed in an outpatient hospital setting.
As highlighted in the UnitedHealthcare Network Bulletin June 2019, certain musculoskeletal surgical procedures (arthroscopic and foot surgery) will be subject to a site of service review when performed in the outpatient hospital under the UnitedHealthcare Musculoskeletal Surgical Procedures Site of Service Policy.
Site of care reviews will not be done as part of the prior authorization process if a procedure will be performed in a free-standing ambulatory surgical center. Authorization will not be required for procedures performed in an emergency room, observation unit, or urgent care center, or during an inpatient stay.
The UHC policy comes on the heels of the UnitedHealthcare Outpatient Advanced Radiology Policy implemented in January 2019 that also incorporates the site of service review process.
The California Medical Association is in the process of evaluating the new UHC policy to better understand how it will affect physician practices and patient care. For more information on the new policy, see UHC’s Site of Service for Certain Musculoskeletal Surgical Procedures (Arthroscopic and Foot Surgery) FAQ.