In a March 1 notice to providers, UnitedHealthcare announced the elimination of prior authorizations for home health services managed by Optum Home & Community (formerly naviHealth). These significant changes will take effect April 1 and apply to Medicare Advantage and dual special needs plans across more than 30 states.<\/p>\n
This targeted reduction is part of UnitedHealthcare’s broader strategy to eliminate approximately 10% of all prior authorization requirements throughout 2025, making it easier for patients to access necessary care without administrative delays.<\/p>\n
The AI algorithms used by Optum Home & Community have faced intense scrutiny in recent years. In 2023, a notable lawsuit emerged when families of two deceased UnitedHealthcare Medicare Advantage members sued the insurer with serious allegations. They claimed that nH Predict, an algorithm developed by NaviHealth, was improperly used to wrongfully deny essential post-acute care.<\/p>\n
In January 2024, the company rebranded NaviHealth<\/a> as Optum Home & Community Care, which now operates as part of Optum Health. This rebranding occurred amid ongoing questions about algorithmic decision-making in healthcare coverage.<\/p>\n An Optum spokesperson provided clarification to Becker’s in 2023 regarding how the nH Predict tool functions:<\/p>\n “The tool is used as a guide to help us inform providers, families and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home,” the spokesperson explained. “Coverage decisions are based on CMS coverage criteria and the terms of the member’s plan.”<\/p>\n Despite these clarifications, legal challenges continue. In February, a federal judge allowed some of the plaintiffs’ claims made in the lawsuit to move forward, suggesting the courts see merit in examining how algorithmic tools influence healthcare decisions.<\/p>\n This newest reduction continues UnitedHealthcare’s multi-year effort to streamline prior authorization processes. The company has demonstrated consistent progress in reducing administrative barriers:<\/p>\n These ongoing reforms reflect the healthcare industry’s broader movement toward reducing administrative burden while maintaining appropriate oversight of healthcare services. The changes particularly benefit Medicare Advantage members, who often require more comprehensive and continuous care coordination.<\/p>\n Healthcare providers have generally welcomed these reductions, as prior authorizations represent a significant administrative burden that can delay patient care and increase operational costs. Patients also benefit from faster access to needed services, particularly important for vulnerable populations covered under Medicare Advantage and dual special needs plans.<\/p>\n The company’s continued focus on reducing prior authorizations demonstrates UnitedHealthcare’s recognition of the need to balance utilization management with streamlined access to care.<\/p>\n Discover the latest payers’ news updates<\/strong><\/a> with a single click. Follow DistilINFO HealthPlan<\/a> and stay ahead with updates. Join our community today!<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"TOOL USAGE CLARIFICATION<\/h2>\n
ONGOING AUTHORIZATION REFORMS<\/h2>\n
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