GI societies spurn UHC’s ‘flawed, misguided’ prior authorization policy for GI endoscopy
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As the effective date of UnitedHealthcare’s prior authorization policy for gastroenterology endoscopy services quickly approaches, the ACG, AGA and ASGE alongside 175 allied organizations have rallied to stop its implementation.
UnitedHealthcare, the largest health insurance company in the United States, has announced that beginning June 1, 2023, commercial plan members will be required to obtain prior authorization for gastroenterology endoscopy services. The list of GI endoscopy procedures includes upper and lower endoscopic and capsule endoscopy procedures as well as 61 other codes.
“The major concern regarding UnitedHealthcare’s new prior authorization policy is that it will delay care for many GI patients, which could potentially lead to negative outcomes for these patients,” Dayna S. Early, MD, FACG, chair of the ACG Board of Governors, told Healio. “This policy will also stress already overburdened practices since this will add extra work to nearly every procedure that is ordered.”
‘Interfering’ with Patient-Provider Relationship
In a letter to Andrew Witty, CEO of UnitedHealth Group, the ACG, AGA and ASGE joined 175 patient advocacy groups, national and state medical societies, academic institutions and individual practices, to oppose the insurer’s prior authorization policy.
“It is flawed and misguided and will harm patients, limit access to care for vulnerable populations, delay diagnosis of colorectal cancer in younger populations, and needlessly increase physician and practice burden,” the groups wrote. “Nearly 1,500 patients and their physicians have sent letters to UHC expressing the harms, both immediate and long term, that the program will cause.”
Early emphasized that the new policy would have the most significant impact on patients who are already exhibiting symptoms, as well as those with an increased risk for colon cancer.
The GI societies noted that the prior authorization policy for GI endoscopy services will have a “chilling effect” on patient compliance to undergo the recommended subsequent colonoscopies following polyp or cancer removal, as well as hesitancy to continue with diagnostic testing when patients present with “red flag symptoms.” The societies noted that 80% of physicians report the prior authorization policies can lead to “treatment abandonment.”
Additionally, the UHC policy is expected to exacerbate access issues for vulnerable populations, compounding an increase in early colorectal cancer diagnoses, health disparities and delayed care due to the COVID-19 pandemic.
“Additional administrative burdens are the main challenges for physicians and their staff, as well as having to communicate this new policy to patients,” Early told Healio. “This may mean delays in providing needed care and amounts to UHC interfering with the doctor-patient relationship.”
The GI societies echoed Early’s sentiments in their letter: “Implementing yet another program that adds to the already high administrative burden physicians face for procedures that are medically appropriate and indicated, and potentially lifesaving, seems like a waste of UHC’s resources and, most certainly, physicians’ time.”
Although screening colonoscopies were excluded from the UHC policy, the GI societies voiced concerns that these procedures will still require prior authorization unless specific coding instructions are provided, and physicians are properly educated on how to handle this.
In response to UHC’s prior claims of “overutilization of invasive non-screening (surveillance and diagnostic) colonoscopy, EGD and capsule endoscopy procedures,” Daniel J. Pambianco, MD, president of the ACG, noted that this was merely an attempt by the insurer to “cut costs by a delaying tactic.”
“[UHC] posited that they are concerned about overutilization as the nidus for this initiative without ever producing the data to substantiate this claim despite numerous, multi-GI society meeting requests,” Pambianco told Healio. “I and the other leaders have offered to review and help remedy the situation if substantiated, by directly educating our members. This has been patently ignored!”
Although UHC claimed the prior authorization policy was “designed to ensure appropriate care based on guidelines,” Pambianco remains skeptical that this policy was intended for the benefit of patients rather than UHC shareholders.
“Using our own guidelines as a cudgel is very concerning, if not outright misdirection,” Pambianco said. “Guidelines are standards that continually change and are updated and, most importantly, are not dictums. There will be deviations based on specific patients’ needs.”
The GI societies likewise voiced concerns about the proposed plan. “UHC’s short-sighted GI endoscopy prior authorization program has not been well designed, will result in delays for medically necessary care for patients, adds unnecessary paperwork burden to physicians and their staff, and may violate [Center for Consumer Information and Insurance Oversight] recommendations,” they wrote.
‘Unreasonable request’ for Policy Pause
“Our societies have met with UHC and recently tried to schedule another meeting on these important issues, a follow-up meeting that was originally recommended by UHC,” Pambianco along with AGA president John M. Carethers, MD, and ASGE president Jennifer A. Christie, MD, wrote in a separate letter. “We continue to offer any clinical data and subject-matter expert as part of our various follow-up requests for further discussion.”
Following extensive inquiries by GI societies, UHC agreed to meet with ACG, AGA and ASGE leaders on May 26 to offer a trade that would pause the GI prior authorization policy in exchange for an “advanced notification program.”
This alternative program would require GI practices and their staff to gather detailed patient data prior to procedures and prepare for a “Gold Card program” being implemented by UHC in 2024. However, pausing the prior authorization policy was contingent on the GI societies’ public support of UHC’s alternative proposal mere days before the June 1 deadline.
“This is a hedge on the part of UHC and a mechanism to have clinicians pay for their data collection that they obviously do not have,” Pambianco told Healio. “The Gold Card program is a canard and an insult to well-intended and diligent physicians. They have been discussing various aspects inclusive of a Gold Card program prior to this latest approach and are now reintroducing its priority in lieu of the negative publicity. This is another ambiguous program not ready for prime time.”
Following the meeting with UHC, the GI society leaders released a joint statement criticizing UHC’s latest proposal, especially at the zero hour.
“Unfortunately, what UHC verbally presented in our meeting was a poorly defined and complicated administrative process,” they wrote. “The GI societies are not in a position to appropriately evaluate the UHC proposal with the limited information presented. Our patients’ health is at stake, and we cannot meet this unreasonable request. The GI societies reaffirm our call on UnitedHealthcare to stop the GI prior authorization policy from going into effect June 1.”
To protest UHC’s prior authorization policy, the Crohn’s and Colitis Foundation with the support of other organizations have planned a rally outside UHC’s national headquarters in Minnetonka, Minnesota on May 31st at 10 am.
References:
- GI society statement: UHC offers to trade GI prior auth for a poorly defined alternative. https://gastro.org/press-releases/uhc-offers-to-trade-gi-prior-auth-for-a-poorly-defined-alternative/ Published May 27, 2023. Accessed May 29, 2023.
- Momentum growing: 175 groups oppose UHC prior auth policy: https://files.constantcontact.com/11178001701/48e5a824-4141-46d3-8512-a70da247b721.pdf?rdr=true Accessed May 29, 2023.
- Letter to UHC CEO from presidents of AGA, ACG and ASGE:https://files.constantcontact.com/11178001701/4e4297f3-671a-4951-b4b8-daa6433a4f0d.pdf?rdr=true Accessed May 29, 2023.
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