After outcry, UnitedHealthcare softens prior authorization policy for colonoscopies

After weeks of protest from physician organizations and patients, UnitedHealthcare has put a controversial new prior authorization policy for gastroenterology procedures on hold. The policy, which requires physicians and patients to get approval from the insurance giant for nearly all gastroenterology procedures, including diagnostic and surveillance colonoscopy, or potentially face paying out of pocket, would have gone into effect on June 1.

Instead, the company is adopting a different policy that it calls “advanced notification,” requiring physicians to let United know they’ll be performing certain gastrointestinal procedures and provide information such as why it’s needed and the patient’s medical history. “This Advance Notification will not result in the denial of care for clinical reasons or for failure to notify,” a UnitedHealthcare spokesperson told STAT in an email.

Still, the frustration from gastroenterology societies and the public outcry following STAT’s reporting of the issue has not fully abated. That’s partly because the advance notification will still burden physician offices and because the program still feels involuntary, said Barbara Jung, the president of the American Gastroenterology Association. Doctors who do not provide the advance notification will be disqualified from United’s “gold card” program, a status that allows doctors to bypass all prior authorizations.

“It was disappointing,” Jung said. “It’s different from prior authorization because there won’t be any denials as part of this, but we don’t have a lot of details.”

In a meeting that the physician groups had with United last week, Jung said that gastroenterologists had, once again, asked United for data on over-utilization and nonadherence to clinical guidelines. “It became clear they had no such data,” Jung said. “And this advance notification was floated, and it became clear that it is a data gathering tool. This is really to help inform a future prior authorization proposal, so it seems like a pre-rollout of prior authorization.”

A statement from United confirmed that the advance notification program is designed to collect data, although United said it was to better understand which physicians will be eligible for the “gold card” program.

The move away from prior authorization and toward advance notification is a step in the right direction, said Molly Smith, a vice president of public policy at the American Hospitals Association. “We definitely had concerns about the prior authorization about certain GI procedures. Prior authorization has been shown to create barriers to care,” Smith said. “We are very pleased with the step that United is taking with the program.”

That’s because advanced notification should neither create new barriers for patients getting lifesaving procedures like colonoscopies and other GI procedures nor should it prevent physicians from getting paid, Smith said. She’s also hopeful that the gold carding program will help alleviate some of the administrative burden that prior authorization policies have on physicians in general, although, “we have seen so far that they are hard to set up. They require data and information to design,” Smith said.

Jung said that while collecting data may be a step in the right direction, United’s advance notification program was unlikely to yield useful data on over-utilization of gastroenterology procedures. United hasn’t provided a standardized way for physicians to provide the needed information, she said. Without a clear data gathering and research plan, it may be difficult to compare information from one clinic to the next — you might not know if you’re comparing apples to apples.

“Our health services researchers had no confidence in this type of data gathering being able to yield a meaningful database to answer their question – if that question is over-utilization,” Jung said.

United also did not indicate there were any plans to share data gathered from the advance notification program with researchers or gastroenterology societies, Jung said.