UnitedHealthcare recently announced that it will implement a process effective December 1, 2024, under which United may deny charges for inpatient and outpatient facility services that United considers "routine."
Commonly referred to as "line-item denials," United's process will specifically target charges for medical equipment, surgical supplies, nursing care and services, and surgical rooms that United alleges are "routine" and not separately reimbursable, but instead included in the provider's room charge. United tries to support the validity of its process by incorporating CMS's definition of "routine services," but as hospitals know, that definition lacks detail; health plans frequently capitalize on CMS's vague definition to issue denials of what are unquestionably non-routine services.
In its announcement of the new process, United states it will apply the process to all commercial and individual exchange benefit plans, regardless of product type or network status. United does not specify the specific CPT/HCPCS codes that will be denied as "routine services." Providers should expect United to request itemized bills in order to identify the specific charges it will deny as routine under this process.
Hospitals that are reimbursed on a percentage-of-charges basis, which would include stoploss claims, are the most obvious targets of the process. But commercial claims paid on a fixed-fee basis (e.g., MS-DRG or APC) are also potential targets if eligible for outlier reimbursement.
You may have a right to object to United's implementation of this line-item denial process. Our managed care team has decades of experience objecting to and litigating against these kinds of health plan processes which can have a material impact on hospital revenue.
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