Dive Brief:
- UnitedHealth has rescinded a plan to require prior authorization for colonoscopies and other endoscopic procedures, following backlash from physician groups.
- UnitedHealth, which operates the biggest private health insurer in the U.S., was set to require prior authorizations for the procedures this week, but announced late Wednesday it was instead enacting an alternative advance notification process.
- Provider groups still slammed the new process, which requires doctors to collect and submit patient data to the insurer before most endoscopic procedures, claiming that it raised documentation requirements on physicians and is a glide path to stricter prior authorization policies.
Dive Insight:
The new advance notification process is the latest development in an ongoing back and forth between UnitedHealth, the parent company of payer UnitedHealthcare, and provider groups over prior authorization.
UnitedHealth was set to enact prior authorization for 61 endoscopy codes starting in June for its more than 27 million commercial beneficiaries. The payer argued the policies would hold physicians to evidence-based practices for clinically appropriate care.
However, after several meetings with provider groups, UnitedHealth agreed to temporarily postpone the prior authorization program in exchange for advance notification. UnitedHealth will run the pilot program collecting data for at least seven months, according to the American Hospital Association, which discussed the policy with UnitedHealth.
In the new program, UnitedHealth requires data in advance of care including member information, requested procedure and diagnosis, referring provider information and rendering provider information and site of service. The payer might also request other details of a patient’s condition or medical history.
The advance notification requirements apply to surveillance, diagnostic and non-emergent colonoscopy, esophagogastroduodenoscopies and capsule endoscopy procedures. They do not apply to screening colonoscopies.
UnitedHealth will not use the data to deny any procedures, and won’t deny any procedures for failure to notify, according to a spokesperson.
However, physicians have to participate in the advance notification process if they want to be considered for UnitedHealthcare’s gold card program, set to begin sometime in 2024. That program will allow certain providers whose prior authorization requests are consistently approved to perform most procedures without needing to get the health plan’s green light.
The AHA said it thinks the advance notification process is a better approach than prior authorization, but other medical groups took a harsher stance against the refocused policy.
The American Society for Gastrointestinal Endoscopy, the American College of Gastroenterology and the American Gastroenterological Association criticized the advance notification process in a meeting with UnitedHealth last week, arguing it requires the same amount of documentation as prior authorization and will have similar repercussions on patient access down the line.
UnitedHealth also hasn’t presented data showing overutilization of colonoscopies or endoscopies to justify the added paperwork, according to the AGA.
“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,” AGA President Barbara Jung said in a Thursday statement.
The provider groups argue preserving quick access to gastroenterological care is integral, as colorectal cancer is the third most common diagnosed cancer and the second leading cause of cancer-related deaths in the U.S. Rates of colorectal cancer are also rising in younger adults.
UnitedHealth announced it planned to greatly reduce its use of prior authorization earlier this year amid a government push to streamline the policies, before unveiling plans to establish prior authorization for some gastroenterology procedures.
