UnitedHealthcare Adjusts Medicare Reimbursement to Reflect CMS Guidelines

Effective July 15, 2025, UnitedHealthcare will implement a 15 percent payment cut on services furnished by selected Advanced Practice Health Care Practitioners as part of the unit's Medicare Advantage plans, as well as Dual Complete plans. The change corresponds to the recommendations of the Centers for Medicare and Medicaid Services (CMS).

The cut will be in place on claims whose listed provider is a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) and/or where a separately contracted non-physician fee schedule is not in place. This update is aimed at aligning the payment practices of UnitedHealthcare with national standards of Medicare.

Some exceptions are quite important. The reduction of 15 percent will be excluded in case of a billing through the SA modifier, indicating that the concerned provider worked together with a physician. The same applies to services that are compliant with the incident-to billing regulations of CMS. This implies that such service was provided directly under the physician's supervision and charged under the National Provider Identifier (NPI) of the physician.

It is recommended that healthcare providers observe the correct billing to prevent inaccurate payments. This involves the right code and ensuring that the documentation is to substantiate the services charged.

For billing or any questions, the providers can also access the UnitedHealthcare Provider Portal, which provides chat support 24/7.

This is one of the ways that UnitedHealthcare is trying to increase the accuracy of billing and adherence to CMS payment policies. The providers will do well to act early to audit their billing practice and get into compliance by the July 15 deadline.