United Healthcare (UHC) has announced it will not go forward with a plan to require prior authorization for colonoscopies and other endoscopic procedures.
Instead, the giant health insurer will adopt an "advance notification" program for nonscreening and non-emergent gastrointestinal procedures.
The company has not made any changes to their policy regarding screening colonoscopies for preventive care, and the advance notification policy does not impact screening colonoscopies.
The advance notification program "will not result in the denial of care for clinical reasons or for failure to notify and will help educate physicians who are not following clinical best practices. Provider groups who do not submit advance notification during this period will not be eligible for the United Healthcare Gold Card program," a spokesperson for the company told Medscape Medical News.
The previously-announced Gold Card program, which is scheduled to start in early 2024, would eliminate prior authorization requirements for providers that meet certain eligibility requirements.
The American Gastroenterological Association (AGA) remains "extremely concerned" that UHC’s advance notification program is a "temporary patch" likely to have significant repercussions for patient access. The organization says the program only temporarily postpones prior authorization requirements set to impact the insurer’s 27.4 million commercial beneficiaries while increasing the administrative burden on clinicians.
The AGA called the program "nebulous" and "poorly defined." It would ostensibly require physicians to input "copious" amounts of highly complex and granular patient data prior to performing colonoscopies and endoscopies, the AGA says.
AGA President Barbara H. Jung, MD, says United Healthcare’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."
"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. UHC is not acting in good faith, and its actions will compromise patient access to potentially life-saving procedures," Jung added.
Recent data show 62% of high-risk patients in the United States who had polyps removed had evidence of delayed or no use of surveillance colonoscopies after 10 years.
"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," AGA Vice President Lawrence Kim, MD, wrote in a news 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," Kim adds.
AGA says it will continue to work closely with its members to assess the full impact of the new requirements and urges UHC to make endoscopy procedures more accessible to patients.
A recent American Medical Association (AMA) survey on prior authorization found that one third (33%) of doctors said the insurance barrier has led to a serious adverse event such as hospitalization, permanent disability, or death for a patient in their care. Nearly half (46%) of physicians reported that prior authorization has led to immediate care and/or emergency department visits.
In a 2023 survey of AGA membership, conducted before UHC announced its proposed prior authorization policy, 95% of respondents said prior authorization restrictions have impacted patient access to clinically appropriate treatments and patient clinical outcomes. And 84% said the burdens associated with prior authorization policies have increased "significantly" (60%) or "somewhat" (24%) over the last 5 years.
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Cite this: United Healthcare Ditches Prior Authorization in Favor of New Policy - Medscape - Jun 01, 2023.