Prior Auth of Cardiac Implants Is Added for Inpatients by United; Claims Seen at Risk

Under a UnitedHealthcare policy,[1] hospitals are now required to get prior authorization for electrophysiology implants after patients already are approved for inpatient admissions. Some experts find it unnerving because they say cardiac interventions potentially could be delayed while hospitals wait for prior authorization, and they may lose payments when they perform urgent procedures without the commercial payer’s say-so. The policy is seen as another example of health plans layering on processes “in an attempt to deny high-cost services,” an attorney said.

Under UnitedHealthcare’s policy, certain cardiology procedures require prior authorization, depending on the setting. For inpatients, prior authorization is required to insert pacemakers and implant cardiac defibrillators. The policy only applies to some UnitedHealthcare plans.

“I have never seen this before. It could potentially be a big deal,” said Juliet B. Ugarte Hopkins, M.D., physician advisor for case management, utilization and clinical documentation improvement at ProHealth Care in Waukesha, Wisconsin. The UnitedHealthcare policy erodes the idea that prior authorization of an inpatient stay includes all services provided during the hospital stay, she said.

“If the admission is approved by a payer, wouldn’t you think that includes all the necessary services provided to the patient during the stay?” said Ronald Hirsch, M.D., vice president of R1 RCM. “When the patient is in a hospital bed, it seems crazy that everyone has to stop and get authorization for the procedure.” It’s one thing that UnitedHealthcare requires prior authorization for outpatient electrophysiology procedures, he said. It’s another thing altogether with inpatients, who, by definition, are sicker than outpatients who have a pacemaker or defibrillator implant scheduled electively, Hirsch said. “The potential for harmful delays is great,” he contends.

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