Insurance companies are not going to stop requiring prior authorization. In fact, insurance companies are increasing their prior auth requirements including Anthem Blue Cross Blue Shield and United Healthcare.
New Prior Auth Requirements for Anthem Blue Cross Blue Shield
We are seeing several commercial plans across the country implement strict prior authorization requirements. We wanted to share a few examples of specific plans but even if these plans haven’t changed requirements in your state yet, you can bet these or other plans will be implementing similar requirements as the year goes on. Effective November 1, 2019, Anthem Blue Cross patients in over a dozen states require prior authorization to receive outpatient physical, occupational and speech therapy services. The initial evaluation does not require prior authorization, but treatment provided on the same date of service as the initial evaluation may require prior authorization depending on the payer rules.
This new program is being overseen by AIM Specialty Health. AIM’s Rehabilitation Program provides a clinical appropriateness review process that encompasses the duration of rehabilitation services. The program includes review of rehabilitative and habilitative outpatient physical, occupational and speech therapy services for medical necessity. The AIM Rehabilitative program for Anthem’s Commercial Membership will relaunch April 1, 2020 for Colorado and Nevada. The AIM Rehabilitative program for Anthem’s Medicare Advantage membership will launch April 1, 2020 for: California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, New York, Ohio, Tennessee, Texas, Virginia, Washington, Wisconsin and Texas.
New Prior Auth Requirements for United Healthcare
Similarly to Anthem, UnitedHealthcare Community Plan has announced they will implement prior authorization for outpatient physical, occupational and speech therapy services in select states. This process has already begun in many states. In addition, UnitedHealthcare Community Plan has announced they will be conducting site of service medical necessity reviews for all speech, occupational and physical therapy services in select states. For some states, the member’s referring physician will be required to submit prior authorization requests for evaluations and re-evaluations.
Once the physician has submitted the request for an evaluation or reevaluation and the request has been approved, the therapy provider can then request therapy visits. In the past, the prior authorization requests were submitted by the therapy provider. If UnitedHealthcare Community Plan does not have the authorization on file prior to the initiation of therapy services, therapy services will be denied and the provider will be unable to balance bill the patient. Additional prior authorization requirements are coming for UHC MyCare plans later this year.
What Can You Do About New Prior Auth Requirements?
Verifying a patient’s insurance is essential. By verifying a patient’s insurance prior to their appointment, you can estimate their patient responsibility, provide them visit limits, and know if their plan requires prior authorization or authorization. These requirements can be a lot for a front desk staff person to handle. LRS can help reduce these significant administrative burdens by taking on your verifications and authorizations so that your front desk can focus on the customer service experience for patients in your facility. Want to learn more about how LRS can assist in your verification and authorization process? Reach out to hello@lincolnrs.com and we can set up a time to chat!
