In June, new prior authorization rules from UnitedHealthcare concerning select gastroenterology procedures will take effect, requiring patients and physicians to seek authorization for gastroenterology endoscopy services, including esophagogastroduodenoscopies, capsule endoscopies, diagnostic colonoscopies and surveillance colonoscopies.
Several physician groups, including the American Society for Gastrointestinal Endoscopy and the California Medical Association, have expressed opposition to the changes, citing patient safety concerns and undue physician burden.
UnitedHealthcare begs to differ, saying that these changes will actually improve patient safety by preventing procedure overutilization.
"Prior authorization is an important checkpoint to make sure a service and procedure is safe and clinically appropriate. It also helps ensure that patients don't pay out of pocket for care they don't need," Tracey Lempner, director of communications for UnitedHealthcare, told Becker's.
"Endoscopy procedures are important diagnostic tools, and are generally safe, but there are a wide range of complications. Complications including bleeding, bowel perforation and anesthesia-related events. Clinical studies have also shown both an over utilization of these procedures and a lack of compliance with clinical guidelines," she said.
According to UHC data shared with Becker's, the average out-of-pocket cost for members is $944 for a diagnostic/surveillance colonoscopy procedure or an esophagogastroduodenoscopy.
"If we know a procedure with known and documented risks is being performed inappropriately, we work to reduce harm and long-term risk and avoid hospital admissions and readmissions for our members," according to a UHC statement on the new policies.
While several medical societies have expressed concerns around potential delays caused by these prior authorization changes, UHC believes that no such delays will happen.
"It is not going to delay care. Our electronic submission process allows for immediate approvals for physicians with a history of following best clinical practices. All other decisions will be made within two business days once we receive all clinical information, which is well within average wait times for clinical procedure appointment scheduling," Ms. Lempner told Becker's.
Additionally, she noted that all clinical information submitted will be reviewed by board-certified gastroenterology specialists.
Last month, physicians submitted 70 percent of their GI prior authorizations through UnitedHealthcare's online portal, and 50 percent were approved immediately through the automated system, according to data shared with Becker's.
"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," Ms. Lempner said.