(This article was updated on Sept. 19 from its initial publication on Aug. 19 to include additional clarifications from UHC.)

In disappointing moves that walk back needed reforms to burdensome prior authorization policies announced in August 2023, UnitedHealthcare has expanded prior authorization requirements within certain plans for follow-up PT visits when services are provided in office and outpatient hospital settings, effective Sept. 1.

See which plans are impacted and which are excluded.  

In response to the UHC decisions, APTA met with the insurer in early September to discuss the problematic issue; a response from UHC is pending. The association also has joined a coalition of providers and facilities advocating against the policy.

Some relief may be available to physical therapy practices that qualify for UHC's new Gold Card program. Slated to begin Oct. 1, the program recognizes practices that meet stated criteria indicating they consistently adhere to evidence-based guidelines. Gold Card providers will not need prior authorization for certain services identified by UHC, including some follow-up visits.

See Page 2 of the Gold Card Program protocol description for eligibility information.

New Optum Healthcare Solutions Requirements

In a similar move, UHC's Optum Healthcare Solutions now requires submission of a patient summary form for prior authorization of treatment visits following an initial evaluation for certain UnitedHealthcare and AARP Medicare Advantage plan members. The announcement of this program expansion was not posted in a provider newsletter; Optum mailed a letter to affected providers in July with a contact phone number of 800-873-4575 for questions. Updated plan summaries can be found at myoptumhealthphysicalhealth.com. Of note: Tier 1A, Tier 1, and Tier 2  providers will not be exempt from this requirement.

Under both programs, initial evaluations continue to be covered without the need for prior authorization. However, prior authorization must be requested if follow-up visits are required,  whether the patient is new to therapy or currently receiving services.

Prior to its meeting with UHC, APTA urged the insurer to reconsider its decision. The association also requested clarifications and received some responses:

• UHC is not posting an official written policy change at this time; it directs providers to the announcement if they want guidance.
• The place-of-service codes being impacted are Outpatient (11 - Office), On-campus Outpatient (22 - Outpatient), Outpatient (24 - Outpatient Facility), Outpatient (19 - Outpatient off-campus), Independent Clinic (49 - Outpatient), and Comprehensive Outpatient Rehab Facility (62 - Outpatient).
• Out-of-network providers will not be required to submit a request for prior authorization for follow-up visits.
• Physical therapist services performed in a skilled nursing facility under Part B are subject to the new requirement.
• Physical therapist services performed in the home are not subject to the prior authorization requirement.

Changes to UnitedHealthcare Community Plan

UHC also announced that yet another line of business — UnitedHealthcare Community Plan — will require a "request for continuation of therapy visits" as of Oct 1.

Even though this policy has not been labeled as a request for prior authorization, the impact is the same, with potential for delays in necessary patient care and added administrative burden on providers. The policy requires providers to submit information such as:

• Weeks of therapy previously authorized or treatment visits attended.
• Patient’s current status compared with evaluation baseline data and the prior progress reports, including objective measures of member performance in functional terms.
• Current physical and functional status compared with prior treatment measurements or assessments.
• Objective measurements that demonstrate continued physical and functional impairment compared with normal values or premorbid level of function.
• Provision of and need for continued skilled services.

APTA continues to work with colleagues from other affected health care disciplines in mounting advocacy efforts against these burdensome new policies and will inform members with any updates.

UHC provides additional information in its announcement Prior Authorization Changes for Outpatient Therapy Services and on a related webpage. For specific questions, contact UHC at 888-676-7768 or Optum at 800-873-4575. UHC encourages providers to voice concerns via either Optum's online portal or email at network_physicalhealth@optum.com. 

APTA members are encouraged to read UHC’s provider newsletters and alerts to stay current on program changes.