UnitedHealthcare agrees to stop requiring referrals before visit to specialists

July 25--Some UnitedHealthcare patients no longer will have to obtain a referral from a primary care physician in order to see a specialist, Missouri's top insurance regulator announced Monday.

UnitedHealthcare will stop imposing referral requirements on non-HMO (health maintenance organization) group plan members starting in October, and the insurer will agree to pay for claims that were previously denied or reduced.

The settlement does not address plans sold to individuals that contain the gatekeeper provision, a widely available product on the health insurance exchange, HealthCare.gov. But it does say that UnitedHealthcare's student health plans will stop using gatekeepers after Jan. 1, 2017.

UnitedHealthcare, the nation's largest health insurance company, also has agreed to pay a fine of $150,000, according to the settlement announced by the Missouri Department of Insurance.

"Consumers should not have to incur the extra time, cost, delay and hassle of going through a 'gatekeeper' just to get access to their very own doctor already in their very own network," John Huff, Missouri's top insurance regulator, said in a statement.

Huff blocked last year two UnitedHealthcare group plans from being sold in the state because of the gatekeeper requirement, a term used to describe the need for a referral to see a specialist.

The plans were known as exclusive provider organizations, or EPOs, which typically do not offer any out-of-network benefits. They're seen as an off-shoot of PPOs (preferred provider organizations), which give patients the option to use both in- or out-of-network doctors. By cutting back on out-of-network access, EPOs provide a way to offer less expensive plans to consumers.

Currently, Missouri law allows only HMO plans to have gatekeepers. Because HMOs operate a tightly contained network of doctors with no access to out-of-network doctors, additional consumer protections are in place.

For patients with complex needs, gatekeeper requirements can get convoluted, health experts say. For example, a patient who has breast cancer is required to keep returning to a primary care physician for referrals for advanced care when a breast surgeon specialist should be the one to advising the patient where to go next in terms of radiology and chemotherapy.

"They're really a hassle for patients and doctors," said Sidney Watson, health law professor at St. Louis University Law School.

EPOs, which first began operating in Missouri in 2014, lack the same consumer protections even though they mirror HMOs in terms of plan design. EPO plans are not permitted in Illinois.

State insurance regulators also alleged that UnitedHealthcare made false entries in statements used in the investigation "by providing the department with transcripts of two call recordings relating to a member complaint that did not accurately reflect the content of the calls."

The transcripts allegedly "omitted material facts," a violation of state law, according to the settlement agreement.

The state also alleged that UnitedHealthcare made inaccurate statements during the investigation regarding member complaints. Some letters relating to member complaints "contained inaccuracies or omissions of material fact."

The department also alleged that UnitedHealthcare failed to maintain call recordings relating to the handling of claims in violation.

In the settlement, the two agreed to develop policies and procedures to ensure the department receives complete and accurate information. However, UnitedHealthcare did deny all of the allegations outlined by the department, according to the settlement.

Samantha Liss --314-340-8017

@samanthann on Twitter

[email protected]

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