175 groups urge UnitedHealthcare to halt GI prior authorization policy

A coalition of 175 organizations have signed a letter urging UnitedHealthcare not to implement a new gastroenterology endoscopy prior authorization policy that is set to go into effect June 1. 

Under the program, prior authorization will be needed for esophagogastroduodenoscopies, capsule endoscopies, diagnostic colonoscopies and surveillance colonoscopies.  

The groups argue in the letter directed to UnitedHealth Group CEO Andrew Witty that UnitedHealthcare's new 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."

The letter was spearheaded by the American Society for Gastrointestinal Endoscopy, American College of Gastroenterology and American Gastroenterological Association. Entities that signed the letter include Rochester, Minn.-based Mayo Clinic, Baltimore-based Johns Hopkins University School of Medicine, the Cleveland Clinic Foundation, the Medical Group Management Association and Los Angeles-based Cedars-Sinai Medical Center. 

Among the groups' concerns is that the prior authorization program will "undoubtedly cause delays in care for high-risk individuals."

"UHC will require prior authorization for most GI endoscopic procedures, many of which are low-volume procedures and are performed for patients who are bleeding, not able to swallow, vomiting or having pain," the letter said. "For example, esophagoscopy (CPT 43200) and esophagoscopy with flexible guidewire dilation (CPT 43226), which are most commonly performed by otolaryngologist-head and neck surgeons, are extremely low-volume procedures required to treat very sick patients, many of whom are at risk for esophageal candidiasis and reflux esophagitis with stricture. Despite the low volume and urgent need to treat this patient population, both procedures will require prior authorization under UHC’s new program. For those patients whose treatment requires prior authorization, 94 percent of physicians report delays in access to medically necessary care."

A UnitedHealthcare spokesperson told Becker's in a statement regarding the letter:  

"Clinical studies demonstrate overutilization of these procedures and lack of adherence to specialty society-endorsed guidelines and recommendations. Up to one-third of upper GI procedures and almost half of non-screening colonoscopies performed for common clinical conditions are not consistent with clinical guidelines. These studies also reveal a wide range of complications with endoscopy procedures, the most serious are bleeding, bowel perforation and anesthesia-related events such as aspiration pneumonia and heart arrhythmias. Further, our review of relevant data demonstrates a two to five practice level variation in the use of both upper and lower endoscopy procedure types, even after adjusting for member characteristics including age and comorbidities.

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.

Our electronic submission process allows for immediate approvals for physicians who have a history of following evidence-based guidelines for the requested procedure. 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."

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