by AJ Riviezzo
An Advantage plan is a plan in which the patient has ‘sold’ or turned over their normal red, white and blue Medicare card/plan to a commercial payer. In this case, United Healthcare (UHC). UHC has a number of different Medicare Advantage plans, one of which is their HMO plan.
Effective May 1st, UHC’s Advantage HMO plan is going to start enforcing their HMO plan rules when it comes to referrals. There has been existing language stating referrals were encouraged to be obtained by specialty providers. Claims were not denying if there was not a referral on file. That is changing. Now the claim will deny if there is not a referral on file. The link to the UHC announcement is HERE.
As a practice, you will need to reach out to those patient’s Primary Care Physicians (PCP’s) and obtain a referral for your services. The ‘good’ news is that most PCP’s will back-date a referral. For all new patients and those who have been receiving treatment and still has further procedures scheduled for May or beyond, I would back date the referral to the initial consultation date.
For new patients, you may receive some push back from the PCPs who are part of a larger system. The system will want to ensure all services are captured within their walls. You will need to remind the PCP’s office that the patient has a choice as to which specialists their network they wish to use. You may have to engage the patient if you continue to receive push back. Some PCPs may require the patient to be seen by them before they will process a referral. You will need to budget for that in your care plan timeline. This is not a new process for the PCP’s so you should not, hopefully, run into any difficulties.