Rather than go through with its controversial prior authorization policy for gastroenterology endoscopy procedures on June 1, UnitedHealthcare (UHC) announced an equally concerning “advance notification” pilot program requiring early notification and the submission of substitute documentation for certain gastrointestinal procedures.
The new process took effect June 1 “and will remain in place until UnitedHealthcare’s gold-card program is launched in early 2024,” according to the payer’s frequently-asked-questions (FAQ) document. In Texas, the policy affects all UHC commercial plan members.
Earlier this year, the Texas Medical Association and roughly 200 national and state medical specialty societies, patient organizations, foundations, and physician groups called for UHC to halt its prior authorization policy requiring physicians and patients to receive approval for nearly all gastroenterology procedures, including diagnostic and surveillance colonoscopies.
In a letter sent to UHC, medicine asserted the policy put cost controls ahead of patient care and could “harm patients, limit access to care for vulnerable populations, delay diagnosis of colorectal cancer in younger populations, and needlessly increase physician and practice burden.”
Despite medicine winning a delay, the new advance notification program appears to provide little reprieve and may similarly increase office burden and cause potential delays to care, says Robert Bennett, TMA’s vice president of medical economics. It requires physicians to notify UHC when performing certain gastrointestinal procedures with information on why the procedure was necessary and the patient’s medical history.
“The pilot program appears to still involve hurdles that physicians must complete prior to getting services ordered for their patients,” he said.
What’s more, UHC says the advance notification policy was implemented, in part, so the payer could collect data on which physicians will be eligible for the payer’s 2024 “gold-card” program, and again cited overutilization concerns that medicine already challenged.
“During 2023, we will use the data received through advance notification to accelerate gold carding for eligible physician groups in early 2024,” UHC said in the policy’s FAQ. “This approach also enables us to identify geographies where underutilization of GI procedures presents an opportunity for us to educate our members about the importance of screening colonoscopies and advance diagnostic GI procedures.”
Additionally, TMA has learned UHC may still implement the initial prior authorization policy with the gold-card program in 2024. Per the FAQ, the payer “may already require prior authorization for some of these procedures if the planned site of service is scheduled to be performed in an outpatient hospital.”
For now, UHC says it will not issue administrative denials for failure to submit advance notification, instead encouraging peer-to-peer discussions between physicians and a board-certified gastroenterologist who, on behalf of UHC, will review the advance notification data. However, practices “must submit advance notification to be eligible for UnitedHealthcare’s Gold Card program,” the FAQ states.
Under the new policy, the following patient services will require advance notification:
- Upper endoscopies, or esophagogastroduodenoscopies (EGDs),
- Capsule endoscopies, and
- Diagnostic and surveillance colonoscopies.
Advance notification is not required for routine screening colonoscopy procedures.
As part of its regular payer meetings, TMA will meet with UHC this summer to discuss challenges the new policy may cause. TMA is concerned about the contribution of such burdens to physician burnout, and the impact of payment delays on access to care.
To share questions or concerns, call TMA’s Billing and Coding hotline at (512) 370-1414 to speak directly with one of TMA’s certified coders, or visit TMA’s Reimbursement, Review, and Resolution Service page.
For educational resources, visit TMA’s Education Center to view courses on Billing, Coding, and Payers.
Alisa Pierce
Reporter, Division of Communications and Marketing
(512) 370-1469