Healthcare Organizations Oppose UHC’s GI Prior Authorization Program

May 25, 2023 - More than 170 healthcare organizations have urged UnitedHealthcare not to implement its gastrointestinal (GI) endoscopy prior authorization program, stating that it will hurt patients and limit access to care.

In a letter to Andrew Witty, chief executive officer of UnitedHealth Group, the organizations said the program could delay diagnosis of colorectal cancer in younger populations and increase physician and practice burden.

Notable signatories included MGMA, the American College of Physicians, and the American Gastroenterological Association (AGA).

Although the prior authorization program for GI endoscopy excludes screening colonoscopy, the policy may impact patients’ willingness to undergo medically recommended colonoscopy exams after polyps or cancers are removed, according to the letter. Additionally, the organizations said that UnitedHealthcare has not provided instructions on how to code screening colonoscopy in a way that avoids prior authorization.

The policy may also exacerbate care disparities among vulnerable populations who currently experience access issues.

UnitedHealthcare’s program will lead to care delays for high-risk individuals in particular as the payer will require patients to receive prior authorization approval for treatment even when a clinician has deemed them at high risk for colorectal cancer, the organizations said.

The program will require prior authorization for most GI endoscopic procedures, including esophagoscopy, a low-volume procedure used to treat patients at risk for esophageal candidiasis and reflux esophagitis with stricture. Many of the CPT codes covered by the GI endoscopy prior authorization program are low-volume and not considered overutilized, the letter stated.

The organizations also highlighted how the prior authorization policy will increase unnecessary administrative burden for providers.

“Because endoscopists often do not know exactly what procedure(s) they will be providing during an endoscopy, UHC clinician representatives have told us that endoscopists will need to request prior authorization for the base code (e.g., 43235 for EGD and 45378 for colonoscopy),” the letter stated.

“Therefore, from a practice operations standpoint, every upper and lower endoscopic and capsule endoscopy procedure will inadvertently require prior authorization, not just the 61 codes listed in UHC’s GI Endoscopy Procedures list.”

Physician burden from prior authorization is already high, with the average medical practice completing 45 prior authorizations per week per physician and dedicating almost two business days per week to the process, according to data from the American Medical Association (AMA).

“UHC’s short-sighted GI endoscopy prior authorization program has not been well designed, will result in delays for medically necessary care for patients, adds unnecessary paperwork burden to physicians and their staff, and may violate CCIIO recommendations. For these reasons, we urge you not to implement the GI endoscopy prior authorization program,” the groups concluded.

UHC’S RESPONSE

The payer maintained that the prior authorization program would not impact screening colonoscopies.

“We have made no changes to our policy regarding screening colonoscopies for preventive care, and this policy does not impact screening colonoscopies. We are asking physicians to follow the guidelines and evidence-based practices developed by their own gastroenterology medical societies to help ensure our members have timely access to safe and clinically appropriate care,” a UnitedHealthcare spokesperson said in a statement provided to HealthPayerIntelligence.

“The physicians who will be most affected by this new policy are those who are not already following these evidence-based practices, which again, were developed by gastroenterology-related medical societies.”

The statement also touched on the patient care delay and physician burden claims from the healthcare organizations.

“Our electronic submission process allows for immediate approvals for physicians who have a history of following evidence-based guidelines for the requested procedure,” the spokesperson said. “For procedures that do not receive immediate approval, decisions are typically made within two business days after receipt of all required clinical information needed for our GI specialists to review the case – well within the average wait time to schedule a service included in this policy.”

In addition, UnitedHealthcare shared clinical studies that have shown overutilization or unnecessary use of non-screening gastroenterology endoscopy procedures, which could lead to medical risks or additional out-of-pocket costs for members.

After discussions with the American Hospital Association (AHA), UnitedHealthcare announced a refocused GI policy on May 31. The policy will require advance notification for gastroenterology endoscopy services rather than prior authorization. The process will rely on additional provider education to address the payer's concerns about potential overutilization.

Editor's note: This article was updated on June 5, 2023, to include information about UnitedHealthcare's new GI policy.