Health Economics News  

Over the past several years, the Health Economics team has provided you with information regarding healthcare reform and how your business will likely be impacted.  As you know, the goal of healthcare reform is to increase access, improve quality and outcomes all while decreasing overall cost. Payers continue to monitor trends and ensure that patients are being treated with evidence based medicine that is cost effective and simultaneously improving health outcomes.

As you may know, United Healthcare recently made changes to their hysterectomy medical policies to ensure that patients are receiving optimal care in accordance with guidelines and clinical data. This is becoming a trend and we expect to see more payers adopt similar guidelines. While these changes in it of themselves will not drastically change the landscape in which you compete, they do bring better awareness to procedures such as ours and should be actively discussed with your customers.

Below, you will find a summary of United Healthcare’s changes and as well as detailed information that will help answer some questions that you may have.    

The latest United Healthcare policy modifications are:

  • Amending hysterectomy requirements to be in line with ACOG recommendation that vaginal hysterectomy is the preferred method of hysterectomy.
  • A new hysterectomy policy for benign tumors which support guidelines stating vaginal hysterectomy is the preferred method of hysterectomy for benign tumors.

 4 key points:

  1. Due to the initiatives associated with healthcare reform, payers are looking for the most cost effective and appropriate ways to treat patients while improving outcomes.
  2. Effective April 6, 2015 United Healthcare will require physicians to obtain a prior authorization and provide proof of medical necessity for certain hysterectomy procedures.
  3. United Healthcare does not allow increased reimbursement for robotic assisted hysterectomies and appears to be discouraging its use with the new procedures and guidelines.
  4. Prior authorization will likely change HOW hysterectomy is performed, but not necessarily significantly decrease its use.

Amending Hysterectomy Requirements

In January, United Healthcare communicated to providers that they would be amending their hysterectomy requirements to reflect vaginal hysterectomy as the preferred method.  Vaginal hysterectomies are associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomies.

Effective April 6, 2015 United Healthcare will require providers to obtain a prior approval and provide proof of medical necessity for certain hysterectomy procedures. The policy states "A clinical denial will be issued, and a prior authorization number will not be issued, if it is determined during the clinical coverage review process that the service does not meet medical necessity criteria."

What does this amendment mean?  

  • Vaginal hysterectomies performed on an outpatient basis do not need prior authorization. All other hysterectomy modalities performed in an outpatient setting must go through the prior authorization process and meet medical necessity criteria.
  • During the prior authorization process it may be determined that the patient does not meet medical necessity criteria and the claim will be denied.
  • Failure to complete the prior authorization process will result in an administrative denial. 

  • Members cannot be billed for services that United Healthcare determines to be medically unnecessary unless the member, with the knowledge of United Healthcare’s determination, agrees in writing to be responsible for the cost of the service.

New Hysterectomy Policy for Benign Tumors

United Healthcare has created a NEW Hysterectomy Policy for Benign Conditions, effective April 1, 2015.  This policy supports that vaginal hysterectomy is the preferred method of hysterectomy for benign conditions:  Studies have shown that a vaginal approach to hysterectomy has fewer complications, requires a shorter hospital stay and is associated with better outcomes than a laparoscopic or abdominal approach.  This policy provides contraindications to the use of laparoscopic power morcellators. 

The policy refers to two additional, but separate policies for Abnormal Uterine Bleeding & Uterine Fibroids, and Robotic Assisted Surgery Reimbursement Policy. 

  • The Abnormal Uterine Bleeding & Uterine Fibroid policy, considers Radiofrequency Endometrial Ablation as standard of care for AUB. 
  • Robotic Assisted Surgery Reimbursement Policy states:  United Healthcare Community Plan considers S2900, (Surgical techniques requiring use of robotic surgical system) to be a technique integral to the primary surgical procedure and not a separately reimbursed service. When a surgical procedure is performed using code S2900, reimbursement will be considered included as part of the primary surgical procedure.

Why is this important?

  • Payers are aware of, and concerned with, the number of hysterectomies being performed particularly due to robotic assistance. 
    • Payers have responded by implementing medical policy and reimbursement guidelines that robotic assisted hysterectomies will not be paid in addition to the normal charges for laparoscopic hysterectomy.
    • Robotic assisted hysterectomy is considered a tool inherent to the procedure, not an additional procedure that is valued separately.