UHC shelves prior authorization for GI endoscopy; replacement ‘could be as bad or worse’
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UnitedHealthcare halted its controversial prior authorization policy for gastroenterology endoscopy services, set to start on June 1, opting instead to move forward with an advanced notification program.
Following widespread backlash from more than 4,500 gastroenterologists and patients, the insurance company announced it would postpone the prior authorization policy that would have affected more than 27 million of its beneficiaries. Instead, UnitedHealthcare plans to implement an advance notification process “for non-screening gastroenterology procedures” under its commercial plans.
This newly enacted program would require physicians to collect and submit patient data prior to performing colonoscopies and endoscopies. Although UHC asserted in a statement that the data would be used to establish criteria for a Gold Card program in 2024 — which would allow adherent physician groups to skip prior authorization for certain procedures — physicians remain skeptical of the insurer’s intentions and how this alternative program could impact patient access.
“UnitedHealthcare’s slap-dash approach to rolling out a policy that will ultimately control patient access to critical, often life-saving, medical procedures flies in the face of common sense and responsible medical practice,” Barbara H. Jung, MD, AGAF, president of the AGA, said in a press release. “It also indicates that UHC does not currently have data that shows any significant overutilization of critical endoscopy and colonoscopy procedures that would ostensibly justify this program or prior authorization. United is not acting in good faith, and its actions will compromise patient access to potentially life-saving procedures.”
‘Roadblocks’ for Patient Access to Care
Despite reversing course on its prior authorization policy, UHC has provided scant information to GI physician groups to reassure them that the advance notification program represents an improvement over its previous plan.
“This delay in implementing the onerous and unjustified prior authorization program may mean that patients won’t be denied care immediately, but the ensuing effects of the program could be as bad or worse for patient access,” according to a statement from the Digestive Health Physicians Association. “UnitedHealthcare is continuing to place roadblocks in the way of patients receiving timely access to care – now in the form of an advanced notification program – without presenting any data of overutilization of services that would justify this program.”
In their updated requirements for gastroenterology services, released late in the day on June 1, UHC noted that their advance notification process is part of an effort to “ensure access to affordable care” to commercial plan members.
“During 2023, we will collect the data received through advance notification to accelerate gold carding for eligible physician groups in early 2024,” UHC stated. “During this period, we will not issue medical necessity denials for procedures that are not aligned with clinical evidence. Additionally, we will not issue administrative denials for failure to submit advance notification.”
The company noted that advance notification will allow UHC to identify areas “where underutilization of GI procedures” occurs and allow the company to educate plan members on the value of screening colonoscopy and other diagnostic GI procedures. For physician practices, however, advance notification represents a significant administrative and resource burden — and a mandatory one for UHC’s Gold Card program.
“It is not clear what would be required for gastroenterology practices to be eligible for the UnitedHealthcare Gold Card program that will exempt patients from burdensome prior authorization requirements,” noted the Digestive Health Physicians Association. “We are concerned that practices will be required to provide even more data in addition to the burdensome paperwork currently required.”
‘Nonsensical and harmful’
Even as UHC proceeds to roll out the advance notification process for its members, physician groups still lack many of the key details for what patient documentation would be needed for the program.
Additionally, although the company cited “overutilization” of non-screening colonoscopy, EGD and capsule endoscopy procedures as a reason for its prior authorization policy, UHC has yet to provide data to reinforce this. Without these details, groups like the AGA still lack any “clear sense of whether a future prior authorization program will or will not target endoscopic indications that are overutilized” or the ability to vet other potential negative effects of the program for patient access.
“The temporary patch UHC has imposed instead lays the groundwork for prior authorization of vital services in the months ahead — threatening patient access, exacerbating administrative burdens, and making clear that the insurer lacks any data to justify its wrongheaded policy,” the AGA said in its statement.
Without clear guidelines and sufficient information from UHC, the advance notification program is likely to exacerbate current administrative and resource burdens that GI practices are experiencing as they continue to catch up on procedures postponed during the pandemic.
“If other prior authorization requirements imposed on patients for specialty care are any indication, we expect to see negative patient outcomes with an enormous cost to patient well-being and physician resources,” Lawrence Kim, MD, AGA vice president, said in a press release. “Given the high percentage of eventual approvals by insurers mandating prior authorization, we anticipate there will be little to no benefit from this prior authorization requirement. When utilized this way, it becomes a nonsensical and harmful policy.”
References:
- Statement from the Digestive Health Physicians Association on UnitedHealthcare’s Advance Notification Policy for Gastroenterology Services. https://www.dhpassociation.org/2023/06/01/uhc-advance-notification-statement/ Published June 1, 2023. Accessed June 6, 2023.
- UnitedHealthcare: Gastroenterology Endoscopy Advance Notification. https://www.uhcprovider.com/en/prior-auth-advance-notification/gastroenterology-prior-auth.html. Published June 1, 2023. Accessed June 6, 2023.
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