United Healthcare Reins in Access to Specialty Care in Medicare Advantage

 by Cheryl Clark

Starting May 1, enrollees in UnitedHealthcare health maintenance organization (HMO) or HMO-point of service Medicare Advantage plans nationwide must get a primary care provider's referral before seeing a wide array of specialists, which several health advocates say will lead to confusion and care delays for millions of seniors.

UnitedHealthcare, the nation's largest provider of Medicare Advantage plans, warned that specialty care without a referral wouldn't be reimbursed and that physicians would be on the hook for absorbing the enrollees' cost of specialty care.

"Claims denied due to missing referrals will be considered provider liability," as of May 1, UnitedHealthcare said in its notice about the policy, first announced last fall. It specifies that plan enrollees "must not be balance billed for services rendered without a valid referral."

The prerequisite has already been the practice in six states: California, Nevada, Texas, Illinois, Missouri, and Nevada. The policy will now apply to the remaining 37 states where UnitedHealthcare offers HMO or HMO-point of service Medicare Advantage plans.

Numerous services are exempted from the new policy, including oncology, ob/gyn, anesthesiology, and emergency or urgent care. Referrals apparently will be required for cardiology, endocrinology, rheumatology, gastroenterology, neurology, otolaryngology, urology, and other specialty fields that were not listed among UnitedHealthcare's exemptions.

A UnitedHealthcare spokeswoman explained in an email to MedPage Today that "stronger PCP [primary care provider] engagement can support earlier diagnosis, better chronic condition management, and more proactive care -- ultimately contributing to improved health outcomes."

Provider Burden

Several health advocates predicted that requiring more seniors to schedule new visits with a primary care provider just to get a referral will confuse both patients and providers and require more work for clinicians, ultimately resulting in delays in timely care. It could mean health conditions will progress as enrollees search and wait for a primary care appointment, especially since primary care is increasingly in short supply.

So why is UnitedHealthcare now expanding this policy so broadly?

"United and other companies are really under the gun to improve their earnings," said Wendell Potter, a former executive with two large health insurers whose whistleblower revelations in 2009 disclosed insurers' unethical practices of denying care.

"Undoubtedly, United sees this as a way to reduce medical spending. But it will clearly lead to confusion and ... older patients not getting the care or medications they need in a timely fashion," he told MedPage Today.

Potter noted that lawmakers in Congress have been pressuring health insurance companies to ease up on policies that unnecessarily delay care, but said that with this and other similar industry practices, "United and the other companies are paying more attention to Wall Street than they are to Washington."

Potter blasted the new referral policy in his Substack newsletter. He wrote: "Some analysts had predicted a kinder, gentler UnitedHealth after a tragedy that made national headlines -- the murder in New York of UnitedHealthcare CEO Brian Thompson in December 2024 -- focused new attention on the company's aggressive use of prior authorization to deny coverage for medically necessary care."

"Instead, the giant insurer has doubled down on ways to drive the highest-cost patients and providers from its system, making it necessary for millions of seniors to scramble to find either new MA [Medicare Advantage] insurers or new doctors. Many undoubtedly will go untreated," Potter wrote.

UnitedHealthcare had about 8.4 million enrollees as of the end of 2025. It does not break out how many are in HMO, HMO-point of service, or other types of Medicare Advantage plans, but HMOs are the most common form of Medicare Advantage plan overall. The company has said it expects to lose 1 million more enrollees this year, partly because it has stopped coverage in more than 100 counties to reduce unprofitable plans.

The difficulties in complying with this new referral policy are exacerbated by the fact that primary care doctors are in short supply, especially in rural areas, Potter said.

"Because of this shortage, people are going to have a challenging time finding a PCP that is nearby or able to accept new patients," he said.

Gina Upchurch, MPH, a counselor with Durham, North Carolina-based Senior PharmAssist, told MedPage Today that insurance agents "are being discouraged from enrolling people" in Medicare Advantage preferred provider organizations, leaving them no other choice for a Medicare Advantage plan besides an HMO or a point of service plan. This shift means a greater number of enrollees could be affected by the new UnitedHealthcare policy, she suggested.

Upchurch said she wonders if UnitedHealthcare "will pay PCPs more to handle the additional administrative burden. I empathize with PCPs who are often not paid to spend time explaining to people why they do not need to see a specialist or get an expensive medication, lab test, x-ray, etc."

Upchurch also is a commissioner with the Medicare Payment Advisory Commission, but she emphasized she was not speaking for that agency that advises Congress on Medicare policy.

Step Backward

David Lipschutz, an attorney and a co-director of the Center for Medicare Advocacy, noted that although requiring primary care referrals for specialty care has been a common practice among HMOs, "imposing this where it didn't previously exist is definitely a step backwards and is not in keeping with promises to address problems with prior authorization."

Another problem is that even if there are primary care physicians within the plan network, enrollees often find that these practices are not accepting new patients, he said. "If you have a pre-existing relationship with a specialist, you shouldn't have to ... jump through extra hoops."

UnitedHealthcare's spokeswoman emphasized that the new policy is not a form of prior authorization, a requirement that has been the target of many physician and lawmaker complaints. In response to this scrutiny, health insurance companies last year pledged to take steps to reduce burdensome delays and unnecessary denials.

"A referral is not a prior authorization, and referrals are not denied," the spokeswoman said. Rather, they are a "care coordination step that helps ensure the primary care provider is involved in guiding specialty care. This change does not add new prior authorization requirements. Existing prior authorization rules remain unchanged."

She added that UnitedHealthcare's goal "is always to help members have access to the right care at the right time. That's why we're providing education and support to help beneficiaries understand what referrals mean for them and how to navigate the new referral process."

The UnitedHealthcare spokeswoman said it will be up to the primary care provider to determine if a face-to-face visit will be required to obtain the referral, or whether the decision can be made on the basis of a phone conversation with the enrollee. She said referrals are submitted electronically, are effective immediately, and are accepted as entered.

https://www.medpagetoday.com/publichealthpolicy/medicare/119958