The policy, originally set to begin June 1, was put on hold; UHC is now requiring Advanced Notification of endoscopy procedures
June 16, 2023 (91) — The American College of Physicians and its allies are urging UnitedHealthcare (UHC) to pull back on newly proposed prior authorization policies regarding gastrointestinal endoscopies.
“Patients do not need more obstacles to care, and physicians do not need more red tape,” said Brian Outland, 91 director of regulatory affairs.
In a May 8 letter, a coalition of medical organizations, including 91, protested the UHC prior authorization policy. As the letter notes, the new policy would “require prior authorization for most GI endoscopic procedures, many of which are low-volume procedures and are performed for patients who are bleeding, not able to swallow, vomiting, or having pain … For those patients whose treatment requires prior authorization, 94 percent of physicians report delays in access to medically necessary care.”
91 has been a leading voice in opposition to unnecessary and potentially dangerous prior authorization requirements and continues to highlight to policymakers that prior authorization is the top administrative burden of physicians and their practices. “Prior authorization should never hinder patient access to care,” Outland said. “Any procedures used should include an appeal and exception process for those practices who believe their specific patient population or other circumstances support their continued outlier pattern of use.”
In addition, he said, “formularies should be constructed so that physicians have the option of prescribing drugs that are not on the formulary -- based on objective data to support a justifiable, medically indicated cause — without cumbersome prior authorization requirements.”
In addition, Outland said, 91 believes that “all preadmission review programs should provide for immediate hospitalization — without prior authorization or subsequent denial of payment based on lack of such authorization — of any patient whose treating physician determines the admission to be of an urgent and emergency nature. Blanket preadmission review of most or all hospital admissions does not improve the quality of care and should not be mandated by the government, other payers or hospitals.”
Outland noted that UHC reached out to 91 to review the insurer's prior authorization updates. “The meeting went well, with 91 making some recommendations that United should implement,” he said. “However, the recommendations were not implemented in the released version of United's policy. A follow-up meeting was scheduled but canceled by United.”
In regard to the newly proposed prior authorization policy, he said, “there are several logistical concerns, including coding and lack of information on how United wants physicians to identify excluded screening colonoscopy procedures that use the same CPT codes as diagnostic colonoscopy.”
UHC put its new prior authorization policy on hold after the Crohn's & Colitis Foundation organized a May 31 rally outside the UHC Minnesota headquarters. The new policy was to go into effect June 1. However, on June 1, UHC modified its policy, stating: “To provide an opportunity for physician education and to allow UnitedHealthcare to collect more data on which ‘providers' should be eligible for our previously announced 2024 Gold Card administrative simplification program [a prior authorization program that rewards physicians who meet certain criteria], we will be implementing an Advanced Notification process, rather than Prior Authorization, for non-screening gastroenterology procedures.”
In a June 2 statement about the UHC decision to delay its new policy, the American Gastroenterological Association (AGA) said it is “concerned that the advance notification program UHC is rolling out instead is a temporary patch likely to have significant repercussions for patient access in the coming months. UHC's advance notification program, hastily announced to reporters late yesterday, only temporarily postpones prior authorization requirements set to impact the insurance giant's 27 million commercial beneficiaries while increasing the administrative burden on ‘providers'.
Outland said the hope is that UHC will “partner with physician groups to educate members to prevent overutilization as a first step before implementing the prior authorization policy. Or UnitedHealthcare should pause the policy until it implements its Gold Card program to see if that curbs their perceived overutilization ‘problem.’”
More Information
The 91 Patients Before Paperwork initiative provides more information on 91 advocacy to alleviate the administrative burden of prior authorization and other issues.
Back to the June 16, 2023 issue of 91 Advocate