番茄社区

Provider groups shared varied reactions to changes that insurance giant UnitedHealthcare is making to its policies for coverage of various gastroenterology procedures, including colonoscopies.

In January, UnitedHealthcare informed providers that beginning June 1, it would be instituting a prior authorization policy. According to the -- which was previously on the insurer's website and dated March 1, 2023, but now appears to be no longer available -- providers would have to "obtain prior authorization for gastroenterology endoscopy services for UnitedHealthcare commercial plan members, in accordance with the terms of their benefit plan."

The notice listed the following procedures as ones that would now require prior authorizations, adding that "screening colonoscopy procedures are not included in this new medical necessity review requirement":

• Esophagogastroduodenoscopies
• Capsule endoscopies
• Diagnostic colonoscopies
• Surveillance colonoscopies

This proposed policy provoked an immediate uproar from provider groups. "On behalf of our members and patients, we urge UnitedHealthcare (UHC) to rescind its March 1, 2023, announcement requiring prior authorization for most gastrointestinal (GI) procedures and services beginning June 1, 2023," the presidents of the American College of Gastroenterology, the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy to UnitedHealthcare CEO Andrew Witty on May 15. "Our societies appreciate meeting with UHC to discuss the announcement and FAQ guidance. 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."

In particular, "medically necessary procedures will be delayed because of UHC's program and 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 letter continued. "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. There is also evidence that many patients with high-risk polyps (e.g., high-grade dysplasia, large adenoma, large flat polyp with EMR [endoscopic mucosal resection]) do not come back in recommended intervals."

On Friday, several provider groups were asked to participate in a phone call with UnitedHealthcare officials, who announced that due to concerns about the prior authorization policy, they were withdrawing it and instead instituting a new . Under this policy, which would -- like the retracted prior authorization policy -- take effect on June 1, providers "will be asked to provide advance notification in lieu of prior authorization for gastroenterology endoscopy services for UnitedHealthcare commercial plan members."

The policy does not spell out what documentation physicians will have to submit for the advance notification, but on the phone call, officials said it would include past medical history, medications, and previous procedures, according to AGA president Barbara Jung, MD, who added that call participants were not given anything in writing prior to or during the call.

The advance notification policy also states that UnitedHealthcare "will collect the data received through advance notification to accelerate 'gold carding' for eligible physician groups in early 2024"; these "gold cards" usually allow physician groups that have them to do most procedures without getting prior authorizations.

"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. Rather, we will provide you the opportunity to engage in a comprehensive peer-to-peer discussion with a board-certified gastroenterologist around clinical guidelines," the new statement continued.

However, although procedures won't be denied, "provider groups who do not submit advance notification during this period will not be considered for the UnitedHealthcare Gold Card program, scheduled to launch in 2024," according to the policy.

"I'm disappointed," Jung said on a Zoom call Thursday with 番茄社区, at which a press person was present. "I was really hoping that they would pause [the policy] and that they would hear our input, and then it would give us an opportunity to further delineate the problem before they would propose an action that potentially just increases the burden of documentation and does not increase better patient care."

The American Hospital Association (AHA) had a different take. "We appreciate UHC [UnitedHealthcare] refocusing its GI policy on provider education to address member concerns about potential care denials and additional preauthorization requirements," said Rick Pollack, president and CEO of the AHA, in a statement Thursday. "We plan to collaborate with UHC to help ensure it meets its goal of providing meaningful education for providers while proactively addressing these concerns."

For its part, a UnitedHealthcare spokesperson told 番茄社区 in an email that the new policy was designed "to provide an opportunity for physician education and to allow us to collect more data on which physicians should be eligible for our previously announced 2024 Gold Card program ... This Advance Notification 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."

UnitedHealthcare said that although endoscopy procedures are generally safe, in some cases complications do occur, including bleeding, bowel perforation, and anesthesia-related events such as aspiration pneumonia and heart arrhythmias. Each year, these complications result in nearly 2,500 hospital admissions and almost 6,000 emergency department visits for UnitedHealthcare members.

UnitedHealthcare also said that studies show endoscopy procedures are overused; the company did not respond by press time to a request for study citations. Jung said she would like to see the data on this issue. "As practicing gastroenterologists, it seems like we can't get people in fast enough," even when they have symptoms.

"We don't understand why we providers have to fill out forms when it doesn't seem to be an issue," she added. "They never showed us [overutilization] data. We suspect there are no such data."

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