UnitedHealthcare pulled back on a controversial prior authorization policy for colonoscopies on Thursday, after its announced new restrictions caused a firestorm of opposition from doctors, patients, cancer care groups and others.
The prior authorization policy, announced in March to begin June 1, would have meant that any person insured by UnitedHealthcare seeking a surveillance or diagnostic colonoscopy would need to get prior approval from the insurer, or potentially pay cash. People who are asked to pay for a procedure often don’t get it, which is why the Affordable Care Act’s preventive services clauses make it law that screening or preventive colonoscopies in low-risk, healthy people between the ages of 45 and 74 are covered without charge.
The subset of colonoscopies for surveillance or diagnostic reasons, the insurer said, would have to meet a different standard.
The announced on Thursday, June 1, the day the new policy was to have gone into effect, that prior authorization would not be required, but that “advance notification” would be. This also raised concerns.
“We will be implementing an Advance Notification process, rather than Prior Authorization, for non-screening gastroenterology (GI) procedures,” UnitedHealthcare said in a statement.
Beginning June 1, the statement said, “You will be asked to provide advance notification in lieu of prior authorization for gastroenterology endoscopy services for UnitedHealthcare commercial plan members, in accordance with the terms of their benefit plan. Please disregard communications that may reference prior authorization language, as it will take a few weeks for our systems to update to the new advance notification process. Please note that screening colonoscopy procedures are not subject to this advance notification process.”
The statement linked the policy to a new UnitedHealthcare “Gold Card” certification for providers, scheduled to go into effect in 2024. The company has announced it will institute a “national Gold Card Program for care provider groups that meet eligibility requirements, eliminating prior authorization requirements for most procedures.”
Prior authorization under fire
Prior authorization by insurers is controversial. Insurers say they need to give authorization in advance to make sure that doctors, hospitals and patients are not wasting money and abusing the system by having procedures willy-nilly. Doctors, hospitals and patients say that the practice of rejecting procedures under prior authorization rules is a way of denying care so that the insurer can make more money — by collecting premiums for health insurance and then paying for healthcare only reluctantly, if at all.
Patients and doctors say they spend a lot of time and energy trying to get prior authorization for some simple garden-variety procedures.
The Affordable Care Act’s preventive services requirements say that procedures and treatments recommended by the United States Preventive Services Task Force should be provided free of cost. The U.S.P.S.T.F. guidelines includes screening colonoscopies for healthy people between 45 and 74; screening mammograms for women from 50 to 74; cervical cancer screening in women from 21 to 65; and other procedures.
United’s prior authorization guidelines, announced in March, were to apply to diagnostic colonoscopies, for people who have symptoms like abdominal pain or blood in the stool, and surveillance colonoscopies, for those who have a history of polyps or a family history of colorectal cancer.
With all three — screening, surveillance and diagnostic colonoscopies — if a polyp is found then it can be removed, which removes or lessens the chances of cancer.
UnitedHealthcare was the subject of a recent investigation by ProPublica into its denial of care to a college student with ulcerative colitis. The investigation revealed that UHC executives went to great lengths to deny his care via prior authorization.
What’s next
In its announcement, UnitedHealthcare said its procedure switch from prior authorization to advance notification would support its plan to name some providers to its “Gold Card” roster.
“The Advance Notification process for non-screening GI procedures supports our efforts to ensure access to safe and affordable care,” the statement said. “During 2023, we will collect the data received through advance notification to accelerate gold carding for eligible physician groups in early 2024.
“During this period, we will not issue medical necessity denials for procedures that are not aligned with clinical evidence. Additionally, we will not issue administrative denials for failure to submit advance notification. Rather, we will provide you the opportunity to engage in a comprehensive peer-to-peer discussion with a board-certified gastroenterologist around clinical guidelines.”
Procedures that will require advance notification, UnitedHealthcare said, include esophagogastroduodenoscopies (EGD), capsule endoscopies, diagnostic colonoscopies and surveillance colonoscopies.
While details are sketchy on the “Gold Card” program, we can surmise that it’s something like another gatekeeping practice by UnitedHealthcare — a way to make things harder for patients so UHC pays less. We wrote recently about a similar gatekeeping practice, the “Centers of Excellence” designation. Who could oppose a Center of Excellence? Who could oppose a Gold Card?
And finally, what happens if you have to pay for a colonoscopy? What will it cost — $600 or $16,000? And how do you get the best price? Here’s our blog post on “what does a colonoscopy cost,” telling you what to do.
