UnitedHealthcare’s prior authorization request for GI endoscopy will spur ‘delays in care’
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UnitedHealthcare recently announced that beginning June 1, 2023, commercial plan members will be required to obtain prior authorization for gastroenterology endoscopy services.
By far the largest health insurance company in the United States, UnitedHealthcare generates more than $286 billion in total revenue — more than double that of the next closest competition, Anthem —and serves approximately 26.7 million Americans.
“By requiring physician offices to go through the prior authorization process, there are going to be delays in care that might even deter patients from coming back for follow-up due to the significant delay,” Austin Garza, MD, from Associates in Gastroenterology in Colorado Springs, Colorado, told Healio. “I think this is going to result in increased diagnoses of later stage colon cancer.”
The procedures impacted by the new prior authorization policy will include diagnostic and surveillance colonoscopies, esophagogastroduodenoscopies (EGD) and capsule endoscopies, a UnitedHealthcare release stated. However, screening colonoscopies will not be included under this new requirement.
Unsure of why the decision was made, Garza voiced concerns that requiring prior authorization for endoscopic procedures will only negatively impact patient care and place additional “administrative burden on the patient and on the physician office.”
“I am not sure why they are doing this,” he said. “It’s clear that this new policy will limit patient access, deter care and jeopardize timely evaluations that prevent cancer.”
In an overview of its prior authorization process, the insurer noted that the policy will ensure its members are given the care they need including the appropriate diagnosis and treatment, supported by the most recent clinical evidence.
“In recent years, studies have shown evidence that overutilization of invasive non-screening (surveillance and diagnostic) colonoscopy, EGD and capsule endoscopy procedures in certain situations exposes patients to unnecessary risks and costs,” UnitedHealthcare stated. “The gastrointestinal endoscopy prior authorization program is designed to help ensure the care our members receive is safe, effective and affordable.”
Although UnitedHealthcare cites overutilization as a potential reason for the new policy,
Garza noted that the decision was made without a “two-way discussion” between UnitedHealthcare and gastroenterologists or GI societies as they were provided no data to evaluate or discuss. Garza argued the requirement for prior authorization will not only hurt patients who need colonoscopies, but also those needing upper endoscopies as well.
He provided an example of a scenario in which one of his patients had trouble swallowing and he had an opening the following day for an endoscopy, thus, providing the patient with timely care. However, with UnitedHealthcare’s prior authorization requirement, this scenario would be quite different. “UnitedHealthcare is going to require that the patient wait longer,” he said. “For symptoms like pain, bleeding or trouble swallowing, by the time patients see me, they have usually seen other providers. They come to us for the diagnostic or therapeutic endoscopy, and we order the appropriate test based on our expertise and established clinical guidelines for care. If they have a delay in scheduling their endoscopy, that gap in time can result in more trips back to the ER rather than getting the definitive care they need.”
References:
- New requirements for gastroenterology services. https://www.uhcprovider.com/en/resource-library/news/2023/new-requirements-gastroenterology-services.html Published March 1, 2023. Accessed April 25, 2023.
- Prior authorization for gastroenterology endoscopy services: Frequently asked question. https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/Prior-Auth-Gastroenterology-FAQ.pdf Accessed April 25, 2023.
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