Despite Last Minute Change, UnitedHealthcare's Policy for Virtually All Colonoscopies and Endoscopies Lays Groundwork for Delays, Disruptions, and Denials of Life-saving Services

Hours before going into effect today, UnitedHealthcare rightly stopped its draconian prior authorization policy that would have forced its 27.4 million commercial beneficiaries to wait for time-sensitive endoscopy services, increasing the risk of disease progression, deferred care, and cancers going undetected

However, the temporary patch UHC has imposed instead lays the groundwork for prior authorization of these vital services in the months ahead —threatening patient access, exacerbating administrative burdens, and making clear that the insurer lacks any data to justify its wrongheaded policy

WASHINGTON, June 1, 2023 /PRNewswire/ -- While the American Gastroenterological Association (AGA) accepts that UnitedHealthcare (UHC) backed off its disastrous decision to begin imposing prior authorization on gastroenterology endoscopy services for all commercial plans starting June 1, AGA remains extremely 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. Clear to the AGA from discussions last Friday, UHC does not currently have data demonstrating any significant overutilization of critical endoscopy and colonoscopy procedures that would justify this program or prior authorization. Since colorectal cancer is the #2 cancer killer and rates are rising in younger adults, now is not the time to increase barriers for patients who need GI care.

The nebulous advance notification program UHC announced late last night will impact virtually all endoscopies and colonoscopies for UHC's commercial plans. The poorly defined "advance notification program" would ostensibly require physician practices to input copious amounts of highly complex and granular patient data prior to performing colonoscopies and endoscopies. UHC claims the data will be used to establish criteria for a Gold Card program in 2024, but the extremely limited details about this newly-enacted program – aside from a proposed framework mandating physicians to provide even more data in addition to the current burdensome paperwork requirements – suggests that UHC does not currently have data showing any significant overutilization of these critical procedures. 

Shortly after UHC publicly proclaimed it would greatly reduce its use of prior authorization, a move applauded by AGA, the nation's largest and most profitable insurer unveiled plans in March to establish a sweeping prior authorization program for most physician-prescribed endoscopy procedures. These services are critical for the early diagnosis of life-threatening diseases such as colorectal cancer and for monitoring patients' disease progression. After more than 4,500 GIs and patients sent letters to UnitedHealthcare's CEO decrying the previously proposed prior authorization requirements and urging the insurance giant to reverse course and the AGA, Medical Group Management Association, and 170 other organizations wrote to UHC urging it to rescind its "short-sighted GI endoscopy prior authorization program," Despite the last-minute reversal, AGA remains concerned that the advance notification program now in effect will adversely affect patient care.

In exchange for the collection of all these data, AGA has no clear sense of whether a future prior authorization program will or will not target endoscopic indications that are overutilized, but the downstream effects of the program could be as bad or worse for patient access as the originally proposed prior authorization policy. The limited information UHC has provided to GI societies indicates the advance notification program proposal is set to create significant administrative and resource burdens for physicians and staff as GI practices continue to see an influx of patients catching up on procedures postponed during the 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," said Barbara H. Jung, MD, AGAF, president of AGA. "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. United is not acting in good faith, and its actions will compromise patient access to potentially life-saving procedures." 

UHC's Gold Card program, a prior authorization program that rewards physicians who meet certain criteria, is set to be announced in 2024. When that happens, thousands of endoscopies and colonoscopies could be disrupted in the first month alone due to cancelled procedures because of the new prior authorization requirements. This new policy comes despite immense pressure from physicians, patients, lawmakers, and regulators to crack down on abusive prior authorization policies. AGA met with UnitedHealthcare to highlight the patient harm this policy will cause and continues to advocate for the policy to be reversed.

Colonoscopies and endoscopies have a long history of being safe, effective, and accurate and should always be performed in alignment with evidence-based guidelines. Research suggests there is an unmet need for colonoscopies in the United States – meaning there is actually underutilization of this crucial procedure. Recent data show 62% of high-risk patients who had polyps removed from their bowels showed delayed or no use of surveillance colonoscopies after ten years, with older age and lower income being associated with a higher incidence of underuse. To ensure appropriate access to medically necessary procedures, AGA will continue to work closely with its members to assess the full impact of the new requirements and urge UHC to rescind its prior authorization policy. 

"If other prior authorization requirements imposed on patients for specialty care are any indication, we expect to see negative patient outcomes with an enormous cost to patient well-being and physician resources. Given the high percentage of eventual approvals by insurers mandating prior authorization, we anticipate there will be little to no benefit from this prior authorization requirement. When utilized this way, it becomes a nonsensical and harmful policy," says Dr. Lawrence Kim, AGA vice president, Denver, CO. 

The latest prior authorization survey from the American Medical Association (AMA) shows that one-third (33%) of doctors say the insurance barrier has led to a serious adverse event such as hospitalization, permanent disability, or death for a patient in their care. Nearly half (46%) of physicians report that prior authorization has led to immediate care and/or emergency room visits.  

According to a 2023 survey of AGA's membership, conducted prior to UHC's proposed prior authorization policy, 95% of respondents say that prior authorization restrictions have impacted patient access to clinically appropriate treatments and patient clinical outcomes. Furthermore, 84% described that the burdens associated with prior authorization policies have increased "significantly" (60%) or "somewhat" (24%) over the last five years. UHC's new prior authorization only exacerbates this trend—to the detriment of patients across the United States.  

About AGA 

The American Gastroenterological Association is the trusted voice of the GI community. Founded in 1897, AGA has grown to more than 16,000 members from around the globe who are involved in all aspects of the science, practice, and advancement of gastroenterology. The AGA Institute administers the practice, research and educational programs of the organization. For more information, visit www.gastro.org. 

AGA is collecting stories and data about how UHC's GI advance notification policy is affecting patients and practices at www.gastro.org/StopUHC.  

SOURCE American Gastroenterological Association