UnitedHealth Ditches Controversial Prior Authorization for GI Procedures for ‘Advance Notification Process’

After weeks of controversy about a prior authorization program for some colonoscopies and other gastrointestinal procedures, UnitedHealthcare is shifting instead to an “advance notification process” that the health insurer says will not include denial of care for clinical reasons.

In a statement issued last night, the largest U.S. insurer by many measures said “effective immediately, we will be implementing an advance notification process, rather than prior authorization, for nonscreening and nonemergent GI procedures” The new process will not include denial of care for clinical reasons or for failure to notify, the statement said.

The advance notification process will be required for nonscreening and nonemergent colonoscopies, esophagogastroduodenoscopies and capsule endoscopies. What exactly it will entail for physicians was not spelled out. Background information provided by UnitedHealthcare positioned the advance notification process as a run-up to United Healthcare’s “gold card” program, which is scheduled to start in 2024 and is designed to relieve providers of prior authorization requirements if they have a track record of following clinical guidelines.

The insurer is characterizing the program as an “educational opportunity” that will include peer-to-peer discussions with board-certified gastroenterologists rather than coverage denials when a procedure is ordered that, in the insurer’s view, is not supported by clinical evidence.

UnitedHealthcare said the program will also allow it to collect additional data to determine which physicians should be included in its gold card program and identify geographic practice variation that may show underutilization of some procedures.

Barbara H. Jung, M.D.,

Barbara H. Jung, M.D., president of the American Gastroenterological Association, issued a written statement later in the evening that criticized the insurer for not acting in good faith and taking a “slap-dash approach to rolling out a policy that will ultimately control patient access to critical, often life-saving medical procedures.”

Jung also said the advance notification policy is an indication that UnitedHealthcare lacks data showing the overutilization that would justify such a program.

The now-shelved prior authorization program had been scheduled to go into effect today. Three gastroenterology professional groups — Jung’s American Gastroenterological Association, the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology — had joined forces to fight it, arguing that putting prior authorization requirements on colonoscopies and other common gastrointestinal procedures would cause delays that could harm patients and bog down physician practices with the bureaucratic, often frustrating, process of getting an insurer to approve coverage for a procedure.

Shivan Mehta, M.D., MBA

“Just about every physician you to talk to or practice with will describe this (prior authorization) is one of the top issues that are really burdening us from being able to take care of our patients appropriately. It leads to delays in care, it leads to incredible burden on our practices,” Shivan Mehta, M.D., MBA, an associate professor of medicine and health policy at University of Pennsylvania’s Perelman School of Medicine and a member of the American Gastroenterological Association’s prior authorization reform task force, said in an interview with Managed Healthcare Executive yesterday before UnitedHealthcare said it was withdrawing the prior authorization program.

United Healthcare has said neither the prior authorization nor the replacement advance notification program apply to screening colonoscopies for colorectal cancer. The gastroenterology groups have said the prior authorization program would affect screening colonoscopies. Mehta said it is often difficult to know in advance whether a colonoscopy is going to be coded for payment as a screening colonoscopy.

UnitedHealthcare’s decision to swap out prior authorization for an advance notification process reframes the disagreement between the insurer and the gastroenterology groups from the familiar turf of prior authorization, a source of long-standing strife between insurers and providers, to one about the lack of detail about advance notification. Mehta participated in a meeting on May 26 between UnitedHealthcare and the gastroenterology groups when insurance company’s representatives mentioned advance notification as an alternative to prior authorization. He said the company’s plans lacked detail and were “just some bullet points, basically, of what this potential alternative option might be.”

A UnitedHealthcare spokesperson said the company is alerting physicians today to the new program and updating a frequently asked questions document on UHCProvider.com.

Mehta said UnitedHealthcare ought to slow down: “There’s no reason to rush implementation of this program while they’re trying to figure out exactly what it is and what all the consequences might be,” he said.