Source: UnitedHealthcare Commercial Reimbursement Policy Update, August 2025

UnitedHealthcare has announced significant changes in its August 2025 Commercial Reimbursement Policy Update, aligning several of its commercial reimbursement rules with Centers for Medicare & Medicaid Services (CMS) payment policies.

Effective September 1, 2025, UnitedHealthcare will apply a 60% reduction in reimbursement for HCPCS code G0463 when billed with modifier PO. This code combination applies to off-campus hospital outpatient visits, and under the new rule, reimbursement will be limited to 40% of the standard rate. The change mirrors CMS’s site-neutral payment approach for provider-based departments not located on a hospital’s main campus.

Who This Affects

This reimbursement cut applies to non-exempt, off-campus outpatient departments, with specific exclusions:

• Emergency departments
• Critical access hospitals
• Rural sole community hospitals
• Facilities in Maryland, Puerto Rico, and U.S. territories
• Indian Health Service and tribal hospitals
• Long-term care, psychiatric, and rehabilitation hospitals

(For the full exemption list, providers should review UnitedHealthcare’s August 2025 Exchange Plan Bulletin.)

Additional Reimbursement Policy Updates

UnitedHealthcare has also outlined several reimbursement changes taking effect on November 1, 2025, including:

• Multiple Procedure Payment Reduction (MPPR): 50% technical and 5% professional component reductions for secondary ultrasound imaging in select states.
• Place-of-Service Denials: Codes labeled “Facility NA” will be denied if billed in POS 21 (Inpatient Hospital).
• Assistant Surgeon & Team Surgeon Policies: Adjusted reimbursement for procedures involving modifiers 80, 81, 82, and 66, especially for HCPCS S codes.

What Your Billing Team Should Do

• Update billing systems: Adjust G0463 claims with modifier PO to reflect the 60% reduction starting September 1 to avoid overpayment issues.
• Train coders and billers: Reinforce correct modifier use and place-of-service coding to prevent denials and underpayments.
• Prepare for November updates: Anticipate imaging and surgical billing changes to keep reimbursement flows consistent.