After dealing with knee pain and stiffness for far too long, Mark was ready for surgical intervention. He was all set with a surgery date and made travel arrangements for the procedure. But the week of his total knee replacement, he learned the request for the surgery was denied.
“I was confused,” Mark said. “The increasing stiffness in my leg almost immobilized me though I could walk somewhat with a cane.”
Through the prior authorization process, clinical reviews of Mark’s case identified that the issue was not in his knee. Instead, it was later determined to be an issue with his hip.
“I was overwhelmed with relief and gratitude that my case was carefully reviewed by UnitedHealthcare’s medical staff,” Mark said. “The authorization process provided a much-needed second opinion.”
The authorization for Mark’s hip replacement surgery was quickly approved, allowing him to keep his same surgery time slot and avoid having to make additional travel arrangements. Mark even called to thank his health care advocate with UnitedHealthcare, who helped coordinate his care, expressing gratitude for the denial of a procedure he never needed.
The prior authorization process, which is a request to your health plan for pre-approval of services or medications, helps ensure health care is safe, necessary and cost-effective. It’s also been described as a checkpoint in the health system to verify that a service or prescription is a clinically appropriate treatment option.
“As a main goal, the rigor applied to the prior authorization process helps to optimize our members’ outcomes by ensuring they receive goal-directed, evidence-based treatment that matches the therapeutic regimen requested yielding clinical benefit,” said Dr. Neil Parikh, chief medical officer of medical management for UnitedHealthcare. “While this robust process involves an end-to-end approach involving various parts of the organization, we aim to ensure the care management plan of our members remains at the nucleus for every consideration.”
This critical step, as evidenced by Mark’s case, helps protect patients by ensuring they receive safe and effective care.
After receiving his hip replacement, Mark said he is on the road to a complete recovery.
“I feel no pain,” he said. “I am walking better after surgery than before.”
