UnitedHealthcare shifts colonoscopy requirements from controversial ‘prior authorization' to ‘advance notification'

CNN

UnitedHealthcare changed its approach on the day that it was going to introduce a new policy for endoscopy, which included colonoscopies.

UnitedHealthcare announced on Thursday that it would no longer require "prior authorizations" for commercial beneficiaries who wish to undergo non-screening endoscopies or colonoscopies. The insurer will instead require 'advance notification' for these services.

UnitedHealthcare requires that providers collect and submit patient data online or over the phone to UnitedHealthcare before performing any procedure. The policy of the insurer regarding routine colonoscopy screenings has not changed.

UnitedHealthcare says that providers who notify them in advance will be eligible to participate in the Gold Card Program, which will be implemented by next year. The program will allow care provider groups who meet eligibility requirements to eliminate prior authorization for most procedures.

In a statement released on Thursday, a spokesperson for UnitedHealthcare said that the process of Advance Notification, instead of Prior Authorization for non-screening or non-emergent GI procedures, will begin immediately. This Advance Notification won't result in a denial of treatment for clinical reasons, or failure to notify. It will also help educate doctors who don't follow clinical best practices. The UnitedHealthcare Gold Card Program will not be available to provider groups that do not provide advance notification within this time period.

UnitedHealthcare's prior authorization plan would have required the enrollee to either pre-approve or pay for a particular procedure.

UnitedHealthcare stated in a fact sheet for healthcare providers that "advance notice" does not lead to denial of treatment for clinical reasons, or failure to notify, and it will educate those providers who do not follow clinical best practices. It says that up to one third of upper gastrointestinal procedures, and "almost half of colonoscopies performed without screening for common conditions", are not in line with clinical guidelines.

Insurance company said colonoscopies are overused, which exposes patients to unnecessary costs and risks. That's why they planned to require authorizations in advance. The plan was criticized by the medical community because it could delay urgent procedures for those who need them. This is especially true at a time where colorectal cases are on the rise among young adults in the United States.

Some medical groups are also concerned about the "advance notice" process.

The American Gastroenterological Association expressed concern Thursday about the potential burden that the 'advance notice' process could place on physicians and medical staff. This is especially true as many gastrointestinal practices are seeing an increase in patients who have 'caught up' with procedures that had been postponed due to the Covid-19 Pandemic.

In a press release, Dr. Barbara Jung said that UnitedHealthcare's hasty approach to implementing a policy which will control access for patients to life-saving medical procedures is contrary to common sense.

Early in May, a number of leading medical groups, including the American College of Physicians and the American Society for Gastrointestinal Endoscopy, wrote to UnitedHealth Group CEO, Sir Andrew Witty, urging him not to implement a program of prior authorization.

They wrote: 'It's flawed and misguided, and it will harm patients. It'll limit access to health care for vulnerable groups, delay the diagnosis of colorectal carcinoma in younger populations and increase unnecessary physician and practice workload.'

Three groups met in late May with UnitedHealthcare at their request to discuss the delay of the prior authorization process in exchange for a 'advance notice' system, which they described as being 'poorly outlined'.

"Unfortunately, the administrative process that UHC presented verbally in our meeting is poorly defined and complex." In a statement, they stated that the GI societies were not able to evaluate the UHC proposal properly with the information provided. 'A pause on the launch of UHC’s prior authorization policy by June 1 requires that the GI Societies publicly support this alternative proposition by early next week. We cannot comply with this unreasonable request. Our patients' lives are at risk.