UnitedHealthcare draws fire from docs over new prior authorization policy for colonoscopies

UnitedHealthcare, facing a storm of backlash from docs over its decision to implement a policy that would require prior authorization for some surveillance and diagnostic colonoscopies, is pushing back against the criticisms.

The insurance giant told Fierce Healthcare that its decision rests on sound science.

“We are asking physicians to follow the guidelines and evidence-based practices developed by their own gastroenterology medical societies to help ensure our members have timely access to safe and clinically appropriate care,” a spokesperson told Fierce Healthcare in an email. “The physicians who will be most affected by this new policy are those who are not already following these evidence-based practices, which again, were developed by gastroenterology-related medical societies.”

But several of those gastroenterology-related medical societies argued against the UHC prior authorization policy. Yesterday, the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy—organizations representing physicians who do colonoscopies—sent a letter (PDF) asking the insurer to rescind the directive, scheduled to take effect June 1.

The organizations noted that UnitedHealth met with them on several occasions to discuss the policy.

“However, each discussion has resulted in more questions, more confusion, more uncertainty, and more frustration over how UHC will implement this program without delaying access to care and straining our practices,” the letter said.

The letter was addressed to Andrew Witty, CEO of UnitedHealth Group, UHC’s parent organization. UnitedHealthcare is the largest commercial health insurer in the country.

“Our electronic submission process allows for immediate approvals for physicians who follow evidence-based guidelines for the requested procedure," the UnitedHealth spokesperson said. "For procedures that do not receive immediate approval, decisions are typically made within two business days after receipt of all required clinical information needed for our GI specialists to review the case—well within the average wait time to schedule a service included in this policy.”

In their letter, the physician organizations said that “the flawed program structure and lack of specific details in your policy announcement and subsequent roll-out guidance has resulted in a groundswell of fear, frustration and administrative confusion across our patient and provider community.”

Other arguments they made against prior authorization for surveillance and diagnostic colonoscopies include:

  • The policy comes at a time when patients are catching up on the colorectal preventive care that they put off because of the COVID-19 pandemic
  • Colon cancer appears to be rising in prevalence among younger people
  • The rising rates of colon cancer in general

“Patients who are already hesitant to get the procedure or have high-risk social determinants of health will decide not to follow through when they are faced with the delay caused by this unnecessary and additional barrier,” the groups said in the letter. “All gastroenterologists have examples of patients with rectal bleeding or other symptoms that require significant counseling by the primary care physician and/or gastroenterologist to convince the patient to follow through with a medically necessary endoscopic procedure.”

The letter said that many individuals with high-risk polyps—high-grade dysplasia, large adenoma, large flat polyp—do not come back at the recommended intervals. Patients who do not have a colonoscopy after a noninvasive colorectal cancer screening test have a 103% higher risk of death compared to those who get the colonoscopy, the provider groups said.

“According to the U.S. Multi-Society Task Force guidelines, undergoing surveillance colonoscopy reduces the risk of colorectal cancer incidences by 43% – 48%,” the letter said. “All of these patients would be subject to this prior authorization on policy and the data show that a significant number will forgo care when faced with the barriers caused by UHC’s program.”

UHC said that the average cost for an esophagogastroduodenoscopy or diagnostic/surveillance colonoscopy procedure is $944 and though they are generally safe, there can be a wide range of complications, that amount to almost 2,500 admissions and almost 6,000 emergency department visits for UHC members for complication-related diagnosis within 30 days of the procedure.

Some recent clinical studies in JAMA Internal Medicine and Gut and Liver focus on complications that can arise from the procedures while studies in Gastrointestinal Endoscopy and the American Journal of Gastroenterology point to the dangers of overutilization.

The UHC spokesperson expressed concern that overutilization and complications can expose UHC members to “unnecessary medical risks and additional out of pocket costs. Up to one-third of upper GI procedures and almost half of non-screening colonoscopies performed for common clinical conditions are not consistent with clinical guidelines.”

Richard Stefanacci, D.O., of the Jefferson College of Population Health at Thomas Jefferson University, told Fierce Healthcare in an email that what’s needed is “much more information as emotions are high, and statements that are not factual or specific to this situation are being made.”

Stefanacci said that the critical information needed is:

  • The issue that UHC is trying to address with this policy.
  • What administrative work is required to comply and how long it will take.

In addition, Stefanacci said he would like to see historical data from UHC on the percentage of colonoscopies that were considered unnecessary, the percent approval rate and, again, an assessment of how much of an administrative burden these unnecessary colonoscopies placed on the health plan.

The heads of the physician organizations that wrote the letter to UnitedHealth Group said they would be willing to listen, too.

“Please reconsider and rescind your forthcoming prior authorization changes,” they wrote. “We would appreciate the opportunity to meet with you again to discuss this issue.”