Following collaborative lobbying efforts from the American College of Gastroenterology and its sister societies, UnitedHealthcare (UHC) announced on June 1 that it will reverse its decision to require an onerous preauthorization process for non-screening endoscopic procedures.
Former Virginia GI Society President and current ACG President Daniel J. Pambianco, MD, FACG, joined patient advocates at a rally organized by the Crohn’s and Colitis Foundation at United headquarters in Minnesota, urging UHC to abandon these new prior authorization rules. “I left yesterday’s patient rally energized and fueled with more passion after speaking and hearing from our patient advocates…We will need this energy too, as this new program only adds to the uncertainty. As you can imagine, this program and announcement raises more questions than answers, and in my opinion, may interfere with the ability to treat patients and practice medicine,” said Dr. Pambianco. “For example, I may have go through a ‘comprehensive peer-to-peer discussion’ with a UHC representative to educate me on adhering to guidelines as to over- or under-utilization if I choose to not participate. Are they actually going to recommend that I may not be doing enough endoscopies? That’s absurd!” added Dr. Pambianco
Full Implications for GI Practices and Patients Remain Unclear
As this new program triggers a whole set of operational challenges, it remains to be seen whether this change is ultimately less burdensome than UHC’s original plans to impose prior authorization restrictions on endoscopy. GI providers will be encouraged to notify UHC prior to performing a procedure and provide certain data United will use to accelerate its Gold Card program in 2024. For the time being, UHC will still pay claims without advance notification or if UHC deems insufficient information was submitted through the provider’s portal.
UHC encourages providers to submit data ahead of time to the company to help roll out its Gold Card Program in 2024. While voluntary, a gastroenterologist will be ineligible for the Gold Card Program without first participating in this advance notification program.
Resources
Full ACG Press Release
June 1, 2023 UHC Statement on Advance Notification Program
UHC FAQ on Gastroenterology Endoscopy Advance Notification
In the News via CNN
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.