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

Mike Blake/Reuters

On the day when UnitedHealthcare requirement was set to start a new requirement for endoscopy services, including colonoscopies, the insurance company shifted to a different approach.

UnitedHealthcare confirmed Thursday that starting this month, it will no longer require “prior authorizations” for commercial beneficiaries seeking non-screening colonoscopies and other gastroenterology endoscopy services. Rather, the insurer is requiring “advance notification” for such services.

The advance notification requirement involves providers collecting and submitting patient data to UnitedHealthcare online or by phone before performing a procedure. There are no changes to the insurer’s policy regarding colonoscopy procedures for routine screenings.

Providers who submit advance notifications will be eligible for UnitedHealthcare’s Gold Card program, which is expected to be implemented next year and, for care provider groups that meet eligibility requirements, will eliminate prior authorization requirements for most procedures, the company says.

“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, effective immediately, we will be implementing an Advance Notification process, rather than Prior Authorization, for non-screening and non-emergent GI procedure,” a UnitedHealthcare spokesperson said in a statement Thursday. “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. Provider groups who do not submit advance notification during this period will not be eligible for the UnitedHealthcare Gold Card program.”

Under its prior authorization plan, UnitedHealthcare would have had to preapprove a procedure, or the enrollee would have had to pay out of pocket for it.

In a fact sheet for providers, UnitedHealthcare said that “advance notification” does not result in the denial of care for clinical reasons or failure to notify and will help educate providers who are not following clinical best practices, as “up to one-third” of upper gastrointestinal procedures and “almost half of non-screening colonoscopies” performed for common clinical conditions are not consistent with clinical guidelines, it says.

The insurance company had previously said that colonoscopies were being overutilized, which “exposes patients to unnecessary risks and costs,” and that’s why it had planned to require prior authorizations. But the plan received criticism from the medical community amid concerns that such a requirement could take too long for people who may need urgent procedures, especially at a time when colorectal cancer cases have been rising among younger adults in the United States.

Some medical groups have also expressed worry about the “advance notification” process.

The American Gastroenterological Association said Thursday that it is concerned that the process of providing “advance notification” to UnitedHealthcare for certain endoscopy services could create “significant administrative and resource burdens” for physicians and medical staff, especially as gastrointestinal practices have seen an influx of patients “catching up” on procedures that were postponed during the Covid-19 pandemic.

“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,” Dr. Barbara Jung, president of the American Gastroenterological Association, said in a statement.

In early May, several of the nation’s leading medical groups – including the American College of Physicians, the American Society for Gastrointestinal Endoscopy and the Mayo Clinic Health System – wrote a joint letter to UnitedHealth Group CEO Sir Andrew Witty urging him to not implement a prior authorization program.

“It is flawed and misguided and will harm patients, limit access to care for vulnerable populations, delay diagnosis of colorectal cancer in younger populations, and needlessly increase physician and practice burden,” they wrote.

In late May, three groups – the American Society for Gastrointestinal Endoscopy, the American College of Gastroenterology and the American Gastroenterological Association – said in a joint statement that they met with UnitedHealthcare, at the company’s request, to discuss delaying the prior authorization program in exchange for the “advance notification” process, which the groups described as “poorly defined.”

“Unfortunately, what UHC verbally presented in our meeting was a poorly defined and complicated administrative process. The GI societies are not in a position to appropriately evaluate the UHC proposal with the limited information presented,” they said in the statement. “A pause in the June 1 launch of UHC’s prior authorization policy requires the GI societies to publicly support this alternative proposal by early next week. Our patients’ health is at stake and we cannot meet this unreasonable request.”

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