The controversial prior authorization policy for colonoscopies that UnitedHealthcare wanted to put into effect today will not take place, the company said last night in a statement.
Instead UHC wants to implement an alternative advance notification process that would require physicians to collect and submit patient data before performing non-screening and nonemergent colonoscopies, capsule endoscopis and esophagogastroduodenoscopies.
That doesn’t settle the matter and in fact could be interpreted as being more ominous to patients and the physicians who perform colonoscopies, Barbara H. Jung, M.D., the president of the American Gastroenterological Association (AGA), said in a statement last night.
“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,” Jung said. “It also indicates that UHC does not currently have data that show any significant overutilization of critical endoscopy and colonoscopy procedures that would ostensibly justify this program or prior authorization.”
At the very least, it will add to physicians’ administrative hassles. The AGA said that “this program requires you to provide even more data on top of the current burdensome paperwork requirements. It is a temporary patch—patients will not be denied care immediately, but the downstream effects of the program could be as bad or worse for patient access.”
AGA, along with the American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG), have been battling UHC for weeks about its original prior authorization policy change.
The organizations sent a joint letter to UHC after meeting with the health plan’s officials last week—a meeting with no satisfactory conclusion—arguing that the new policy, which would require prior authorization for some diagnostic or surveillance colonoscopies, would endanger patients. UHC responded that it’s following the science and that the overuse of colonoscopies could put patients in danger as well.
The AGA asked members to share their stories about how this policy would affect their practices and patients. “This misguided program involves a poorly defined and complicated administrative process that will ultimately impact millions of Americans who require colonoscopies or endoscopies and exacerbate administrative burdens.”
Despite UHC being the biggest health plan in the United States, it looks as if for now at least it’s on its own in this battle. A spokesperson for Aetna told Fierce Healthcare that that company has no intention of changing its colonoscopy policy. Humana, Cigna, HCSC and Kaiser Permanente did not return a request for comment.
In its statement last night, UHC said it wants doctors “to provide advance notification in lieu of prior authorization for gastroenterology endoscopy services for UnitedHealthcare commercial plan members, in accordance with the terms of their benefit plan. Please note that screening colonoscopy procedures are not subject to this advance notification process.”
UHC plans to use the data on colonoscopies that it collects this year to determine for 2024 which physician groups will be eligible for its Gold Card program, in which physician groups that meet certain eligibility requirements can skip prior authorization for most procedures.
“During this period, we will not issue medical necessity denials for procedures that are not aligned with clinical evidence,” UHC said in the statement. “Additionally, we will not issue administrative denials for failure to submit advance notification. Rather, we will provide you the opportunity to engage in a comprehensive peer-to-peer discussion with a board-certified gastroenterologist around clinical guidelines.” This oversight policy started today.
UHC said that the approach will allow it to educate physicians in order to cut down on unnecessary colonoscopies.
That’s something that the American Hospital Association (AHA) also noted in a special bulletin that it sent to members today. “The focus on provider education should diminish the risk of patient access issues by removing the need for preauthorization in advance of the service and the accompanying risk of coverage or payment denials,” the AHA stated.
Rick Pollack, AHA president and CEO, said in the statement that “we appreciate UHC refocusing its GI policy on provider education to address member concerns about potential care denials and additional preauthorization requirements. We plan to collaborate with UHC to help ensure it meets its goal of providing meaningful education for providers while proactively addressing these concerns.”