Payers

UnitedHealthcare backs off contentious prior auth plan

The insurer updated the policy after pushback from hospitals and providers.
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UnitedHealthcare (UHC) this week halted a contentious plan that would’ve required the insurer to sign off before a patient could undergo certain gastroenterology procedures.

The company will now require advance notification—instead of the prior authorization mandate it announced earlier this spring—for some gastroenterology endoscopy services for commercial plan members. Critics had argued the new prior authorization requirement could make it harder for patients to afford colonoscopies or endoscopic procedures, potentially resulting in some cancer cases going undetected.

UHC argued that the updated policy, which took effect for most members on June 1, supports its “efforts to ensure access to safe and affordable care.” The insurer said it “will not issue medical necessity denials for procedures that are not aligned with clinical evidence” or administrative denials for those who fail to submit advance notification.

“This approach also enables us to identify geographies where underutilization of GI [gastrointestinal] procedures presents an opportunity for us to educate our members about the importance of screening colonoscopies and advanced diagnostic GI procedures,” UHC noted as part of its updated requirements.

American Hospital Association President and CEO Rick Pollack lauded UHC for “refocusing its GI policy on provider education to address member concerns about potential care denials and additional preauthorization requirements,” he said in a statement.

But the American Gastroenterological Association (AGA)—a chief critic of the prior authorization proposal—called the updated policy “a temporary patch,” and cautioned that “the downstream effects of the program could be as bad or worse for patient access.”

“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 statement. “It also indicates that UHC does not currently have data that shows any significant overutilization of critical endoscopy and colonoscopy procedures that would ostensibly justify this program or prior authorization.”

Screening colonoscopy procedures will not be subject to the advance notification requirement and will “only require prior authorization for site of service medical necessity review” if planned at an outpatient facility, according to UHC. The advance notification policy will apply to esophagogastroduodenoscopies, capsule endoscopies, diagnostic colonoscopies, and surveillance colonoscopies for members in all states except Kentucky, New Mexico, and Rhode Island.

UHC will collect data on the advanced notification process in 2023 to determine physician eligibility for UHC’s national Gold Card program. Provider groups that fail to submit advance notifications during that time won’t be considered for the program, which is set to launch in 2024 as part of an effort to eliminate prior authorizations for most procedures.

Navigate the healthcare industry

Healthcare Brew covers pharmaceutical developments, health startups, the latest tech, and how it impacts hospitals and providers to keep administrators and providers informed.