New United Healthcare policies regarding hysterectomy may impact preauthorization and reimbursement

    By: Colleen Hughes on Apr 22, 2015

    AUGS Member Alert: New UnitedHealthcare policies regarding hysterectomy may impact hysterectomy preauthorization and reimbursement

    Members are aware in many cases of increased scrutiny by insurance payers in recent years regarding preauthorization of surgical procedures and hospital admission duration.  Surgeries involving hysterectomy have been particularly subject due in part to the common nature of the procedure and potential outcomes associated with different surgical approaches.  ACOG Committee Opinion #444 (2009) states “evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomies”. 

    AUGS continues to maintain the following priorities regarding surgical procedures:

    • Patient safety and optimal surgical outcomes are of the highest importance

    • Different methods of hysterectomy may be preferable in various clinical situations

    • Physician and patient autonomy to determine the right procedure for the individual woman through the process of informed consent should be respected

    UnitedHealthcare published a Network Bulletin dated January 2015 announcing a new policy, effective April 6 2015, which is relevant to this issue.  Titled “Hysterectomy Prior Notification Requirements”, the policy states the following:

    • All hysterectomies not coded as outpatient vaginal procedures will require prior authorization.  Outpatient vaginal hysterectomies do not require this authorization prior to surgery.

    • Providers planning other surgical routes for a patient such as laparoscopic, robotic-assisted, or abdominal hysterectomy, or planning an inpatient hospitalization, will be required to call to obtain preauthorization of the planned procedure.  UnitedHealthcare policy further states “…if it is determined during the clinical coverage review process that the service does not meet medical necessity criteria…”, coverage will be denied.

    AUGS leadership are concerned that this policy has the potential to seriously restrict the capacity for physicians to provide optimal care for women considering hysterectomy as part of their surgical intervention for conditions such as pelvic floor disorders, where the best route of surgery may be determined in part by other clinical considerations.  Other payors may follow suit.  There is further potential for future impact on tiering of providers and graduated reimbursement based on compliance with such policies. 

    AUGS will be monitoring these developments closely on behalf of its members and their patients.   Policies that require specific action by providers to ensure coverage may be intrusive to the surgical decision making process between a patient and her provider and require additional provider and administrative staff time.  

    AUGS needs your help.  If you or your staff has had to perform additional actions prior to a surgical procedure in order to conform to coverage policies, we would like to know more. Specifically:

    • What was the circumstance where additional action was required?

    • What was the additional burden on provider time?

    • What was the additional burden on your administrative staff?

    • Did you perceive an impact on clinical decision-making?

    AUGS members are encouraged to contact AUGS or the coding committee via email at info@augs.org.

     

     

    Released: April 22, 2015, 8:44 am
    Keywords: Announcements


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