UnitedHealthcare: Medical Necessity and New Technologies
A refrain that is frequently heard when speaking with physicians about insurance companies involves medical necessity: "Why is this patient's care being denied? Doesn't the insurer know that it is medically necessary?" When there is dissatisfaction about insurance company reviews, it usually involves either questions of medical necessity or new technologies. To find out how UHC deals with these sometimes problematic questions, OSMA spoke with Dr. Gajdowski and Dr. Shonk to find out more. Many times issues of denial revolve around benefits and eligibility for a given patient. If the patient is eligible and covered, then the question becomes a medical one: What is the appropriate care? To minimize the subjective nature of a medical necessity determination, UHC has moved away from making a case-by-case determination in favor of using national standards. Links to these standards can be found on UHC's Web site in the Administrative Guide.
For the UHC Administrative Guide click here.
In 2000, UnitedHealthcare adopted the Milliman and Robertson Care Guidelines as a reference for evidence-based care, primarily with respect to services performed in hospitals and long-term care facilities, as well as the UHC Radiology Notification Program. UnitedHealthcare does not perform medical necessity review. UnitedHealthcare uses a persuasion model based upon evidence based guidelines for a given episode of care. When differences of opinion occur, the medical directors at UHC will consult the relevant medical literature, including applicable Milliman and Robertson care guidelines as a basis for best clinical practice. UHC's medical directors state unequivocally that they are open to "physician to physician" discussion to achieve a resolution of patient care issues. In that UnitedHealthcare does not practice medical necessity review, if the requested service is a covered benefit, the requested service will be paid according to the member's benefit if so requested by the treating physician, even in the event of a difference of opinion between the treating physician and the UHC Medical Director. The final clinical decision as to whether a covered service is performed is always left up to the physician.
New clinical technology or new diagnostic testing data is reviewed by members of UHC's medical staff at its corporate headquarters in Minnetonka, Minnesota. In Ohio, new technology is also evaluated on an annual basis and regular reviews are conducted on clinical data. Questions regarding medical review should be directed to the Ohio medical directors: Drs. Gajdowski and Shonk at the contact information listed on the company overview and key contacts page.
Steps You Can Take to Better Utilize Services Available from UHC
Bookmark www.UnitedHealthcareOnline.com on your computer. This will help you access the UHC Web site more easily.
Although questions regarding benefits, coverage and claims can be answered using this Web site, the most valuable tool available online is UHC's Administrative Guide.
For the UHC Administrative Guide click here.
The Administrative Guide includes:
- phone numbers for every UHC department;
- payment information on how claims are processed and how payments are made;
- notification information;
- clinical guidelines used by UHC and links to the national standards;
- an explanation of the UHC customer ID cards;
- information on Medicare claims;
- updates on UHC product lines;
- dispute resolution procedures.
Use the UHC Voice Portal System. If an office would prefer to speak directly with a UHC department, this new phone system will help physician offices access information quickly. Dial (877) 842-3210, enter your tax ID#, then state whether you are calling about a claim, benefits and eligibility, notification of an upcoming service, privacy information or some other area such as credentialing. Your call will be routed directly to the appropriate department. There is a helpful flow chart a physician's office can print out and refer to when using the UHC Voice Portal System.