Defending UnitedHealthCare…Finally

It is all too common for patients and physicians to take to social media to air grievances about insurance company misdeeds.

A recent case generated the usual outrage and anger across Instagram, LinkedIn, other social media platforms, and the usual press sources, and even resulted in the insurer sending the doctor a cease-and-desist letter. And while the exact circumstances are not always clear, and obviously the medical records and transcripts from calls are not available, here is what appears to have happened.

A patient was scheduled for breast reconstruction surgery. It is not known if the patient had a commercial, managed Medicaid, or Medicare Advantage (MA) plan. From a letter reportedly from UnitedHealthcare (UHC), the surgery was prior-authorized as outpatient. As this surgery was approved as outpatient, I would presume that either the patient was not a MA patient, or was MA, but was going to have one of the reconstruction surgeries that is not on the Medicare Inpatient-Only List.

And now I speculate further. At some point, perhaps in the pre-operative area, the surgeon informed the staff that the patient would be staying overnight for her recovery. It appears that this was not what was expected, and someone determined that in order for the patient to stay overnight, the insurance would need to be contacted to get approval for inpatient admission. 

A call was made to UHC, perhaps by the OR staff or the scheduling staff, and as would be expected, the request for inpatient admission approval was denied, with UHC offering the opportunity for the surgeon to talk to a medical director at UHC to discuss the case. By this time, the surgery had started, and the surgeon was scrubbed in.

She was told she needed to speak with the insurance company, and the social media uproar ensued. The patient was treated safely and properly, she stayed overnight, the physician wrote an inpatient admission order, the hospital billed an inpatient admission, and the claim was denied, appropriately so.

Now, here is what potentially went wrong, again with the caveat that I am basing this on public information only. First, when a surgeon schedules an outpatient surgery, they should be asked to indicate if the patient will be discharged the same day of surgery, or whether the patient expected to require an overnight stay as part of their planned recovery. The scheduling form should have both options.

When one thinks about outpatient surgery, one commonly pictures the patient having the surgery, waking up in the recovery room, eating a few crackers, and then being discharged home. But outpatient surgery can also be scheduled to include an overnight stay. This is commonly done with a multitude of surgeries, including cholecystectomy, hysterectomy, and joint replacement.

In the past, this was called “23-hour observation,” but the proper terminology to avoid those recovery hours being billed as observation services is “routine overnight recovery” or “extended recovery.” The use of overnight recovery varies among surgeons and institutions. Many hospitals are implementing Enhanced Recovery After Surgery (ERAS) programs, and having great success avoiding the overnight stay and shortening the in-hospital recovery period for other surgeries.

In this case, when the surgeon noted to the staff preoperatively that the patient would require an overnight stay, the staff’s call should have been to the hospital’s utilization review (UR) staff or physician advisor (PA), not to the insurer. The UR staff or PA would have reassured the staff and the surgeon that the outpatient approval can include the patient remaining overnight for recovery, and that no additional contact with UHC was necessary.

The room reservation staff would then be alerted that the patient will need a bed for the night on the surgical unit – and all would have been fine, although the staff would certainly have preferred to know this ahead of time to enhance advance planning for all the patients needing a bed.

Now, did UHC insist that the surgeon break scrub to take the call from their medical director? I would certainly hope not, as that would be a fireable offense by whomever would request that – and UHC claims that did not happen. But again, without firsthand knowledge, I cannot comment further.  

The use of prior authorization by insurers has received significant attention, deservedly so, as has aggressive denial of care, with UHC even making efforts to hide their actions, as I outlined in a recent LinkedIn post.

But in this case, the social media outrage was not warranted. It was a simple problem that could have been prevented with a robust UR process and access to the right people – especially a physician advisor.