In a March 1 notice to providers, the health insurer said it will eliminate prior authorizations for home health services managed by Optum Home & Community, formerly naviHealth. The changes, which take effect April 1, apply to Medicare Advantage and dual special needs plans in more than 30 states.
The cut is part of a broader effort to eliminate around 10% of UnitedHealthcare’s prior authorization requirements in 2025, according to the company.
AI algorithms used by Optum Home & Community have come under scrutiny. In 2023, the families of two deceased UnitedHealthcare Medicare Advantage members sued the insurer, alleging nH predict, an algorithm developed by NaviHealth, was used to wrongfully deny post-acute care. In January 2024, the company rebranded NaviHealth as Optum Home & Community Care, which is part of Optum Health.
The nH Predict tool is not used to make coverage decisions, an Optum spokesperson told Becker’s in 2023.
“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 said. “Coverage decisions are based on CMS coverage criteria and the terms of the member’s plan.”
In February, a federal judge allowed some of the plaintiffs’ claims made in the lawsuit to move forward.
UnitedHealthcare has cut back on prior authorization requirements in recent years. In 2023, the company eliminated 20% of prior authorization requirements, and in 2024, the company introduced a gold card program, which allows some providers to skip prior authorization for certain services.
