California Medical Association
January 18, 2008
CMA has asked the Department of Insurance to require that United Healthcare rescind its new Advance Notification Protocol. This onerous protocol requires physicians to notify United before admitting patients to the hospital and mandates that if physicians don’t comply, they won’t be paid.
United is calling this “notification” rather than “preauthorization,” but is requiring physicians to provide the exact same information that other insurers require for preauthorization, without a guarantee of payment. In our request to the DOI, CMA set forth several problems with the protocol, including United’s failure to notify physicians in a timely manner of a material change to their contracts, as required by law. CMA believes the protocol is an attempt by the insurer to improperly insert itself into decisions regarding patient treatment.
CMA also believes that it unreasonable to expect a busy physician practice to allocate the time and resources necessary to comply with United’s protocol without a guarantee of payment. In order to be compliant with the protocol and to be eligible for payment, physicians may be forced to divert resources from patient care to administrative tasks.
This protocol is one of a series of policies recently announced by United that CMA believes are unfairly onerous, punitive to physicians, and detrimental to patient care, and that we are seeking to have overturned.
http://www.calphys.org/html/cc597.asp
Supporting documents:
http://www.calphys.org/assets/applets/poizner_letter_012108.pdf
Comment:
By Don McCanne, MD
UnitedHealthcare’s “Advance Notification” protocol is very similar to established preauthorization protocols in that the insurer can deny payment if the process is not followed prior to the provision of health care services. The physician must submit the same information, in advance, that is required for preauthorization. The important difference is that fulfilling this identical notification requirement no longer ensures that the physician will be paid.
This appears to be yet another wasteful administrative burden placed on the physician that serves no purpose other than using a technicality to relieve UnitedHealthcare from the responsibility of paying for legitimate services.
Actually, it is much more than that. It is a return to the intrusive managed care policies of the 1990s that were so offensive to patients and physicians alike. Following is an excerpt from a document from UnitedHealthcare on “Advance Notification” (accessible at the “Supporting documents” link, above):
12. Why does UnitedHealthcare require notification for certain services and inpatient admissions?
Notification facilitates the ability for UnitedHealthcare to provide supportive clinical support and education, such as:
* Perform pre-op education for the patient and ensure adherence to nationally recognized guidelines in order to maximize quality and cost-efficiency
* Facilitate post-op discharge planning to optimize clinical outcomes, e.g. facilitated treatment plans post-hip and knee replacement surgery or spine surgery in order to reduce unnecessary variation in health care delivery
* Refer patients to Centers of Excellence (e.g., congenital heart disease)
* Refer patients to appropriate in-network physicians, other health care professionals or facilities
* Refer patients to our case management and disease management programs
Notification also enables UnitedHealthcare to assist with non-clinical support and education, such as:
* Educate network physicians, other health care professionals or facilities regarding enrollee benefits (e.g., some services are not covered under certain benefit plans)
* Educate network physicians, other health care professionals or facilities regarding the impact of directing enrollees to out-of-network providers (including explanation of increased patient out of pocket costs for out-of-network services) and assisting with identification of available alternative network physician, other healthcare professional or facilities
* Maximize enrollee benefits (out-of-network services may be paid at in-network benefit levels under certain special circumstances)
