It’s been just over 1 month since UnitedHealthcare (UHC) launched its advance notification program requiring providers to record nonscreening colonoscopy and other gastroenterology procedures to be eligible for its 2024 Gold Card program.
The program, which will begin next year, may eliminate prior authorization requirements for providers who successfully complete the advance notification program this year. However, there is no guarantee that providers who complete the advance notification program will be enrolled in the Gold Card program, which means they would have to seek prior authorization for nonscreening procedures, according to the American Gastroenterological Association.
While UHC has provided some information about how advance notification works, there are many unanswered questions, said Barbara H. Jung, MD,AGAF, AGA president.
AGA
Dr. Barbara H. Jung
“UnitedHealthcare’s haphazard approach to rolling out a policy that will ultimately control patient access to critical, often lifesaving medical procedures are the opposite of what should be our common goal of expeditious access to essential care,” she said in a written statement.
The advance notification program was announced on June 1 when UHC said it was dropping its controversial prior authorization program, which was due to go into effect that day.
AGA is concerned that UHC’s advance notification program is merely a delay tactic because prior authorization may be required next year for providers who are not accepted into the Gold Card program. Providers who are not accepted into the program may face delays in administering procedures due to the need for prior authorizations. Thousands of endoscopies and colonoscopies could potentially be disrupted in the first month alone due to canceled procedures because of new prior authorization requirements, they said.
UHC has been trying to rein in health care costs by first considering prior authorizations for most gastrointestinal (GI) endoscopic procedures, except for screening colonoscopy, but ultimately adopting advance notification. Providers, UHC has said, don’t always follow evidence-based medicine treatment recommendations or they overutilize procedures. Their goal, according to a summary document it issued outlining changes to advance notification and prior authorization requirements, is “better care, improved health outcomes, and lower costs.”
“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 nonscreening colonoscopies performed for common clinical conditions are not consistent with clinical guidelines,” UHC stated in an FAQ. “A UHC review of upper endoscopy and lower endoscopy procedures performed in 2022 revealed two- to fivefold practice-level variation in the use of both procedure types, even after adjusting for member characteristics including age and comorbidities.”
However, according to a statement from the AGA, it has not seen utilization data specific to UHC: “It is clear that UHC does not currently have any data indicating significant overutilization of critical colonoscopy and endoscopy procedures and therefore no justification to impose burdensome barriers like prior authorization.” AGA also pointed to research showing there is an unmet need for colonoscopies in the United States, which suggests there is an underutilization of this crucial procedure.
“AGA has expressed its willingness to work collaboratively with UnitedHealthcare to address any concerns and educate physicians, but communication and transparency with the insurer are nearly nonexistent. Instead, the GI community is confronted with a nebulous concept called advance notification, which is not conducive to seamless patient care. Ultimately, it appears advance notification will form the basis of prior authorization, which we know can delay, disrupt, and deny timely care,” Dr. Jung said.
