Updates to Medicare Advantage reimbursement for Advanced Practice Health Care Practitioners

Consistent with the Centers for Medicare and Medicaid Services (CMS) and in accordance with provider contracts, UnitedHealthcare will apply a 15% payment reduction to all services rendered by Advanced Practice Health Care Practitioners who do not have a separately contracted non-physician fee schedule for UnitedHealthcare® Medicare Advantage and UnitedHealthcare® Dual Complete plans. This adjustment will begin with claims processed on or after July 15, 2025.

What claims are impacted?

The reduction applies to claims for UnitedHealthcare Medicare Advantage and UnitedHealthcare Dual Complete plans billed with one of the following CMS-recognized Advanced Practice Health Care Practitioners listed as rendering provider:

Physician Assistants (PAs)
Nurse Practitioners (NPs)
Clinical Nurse Specialists (CNSs)

To help ensure accurate reimbursement, services must be billed according to CMS correct coding guidelines. The 15% reduction will not apply to services performed in collaboration with a physician when appropriately billed with modifier SA.

Additionally, the reduction may not apply to services that meet CMS criteria for “incident to” billing—where care is delivered under the direct supervision of a physician and the service is billed under the physician’s NPI. Health care professionals should ensure documentation and coding align with CMS requirements for these scenarios.