Some gastroenterologists have expressed concern over a lack of clarity in eligibility requirements in UnitedHealthcare's new gold card program, Gastroenterology & Endoscopy News reported Oct. 18.
Here are five takeaways from the report:
1. The program was introduced on Sept. 1, and went into effect on Oct. 1. The program aims to reward eligible provider groups who follow certain procedure guidelines and allow qualifying practices to bypass typical prior authorization processes.
2. No endoscopy services have thus far been included on UHC's list of gold card-eligible services, leading some gastroenterologists to question the decision-making process behind the program's eligibility criteria.
"Who is making those clinical decisions on their side? If a practice loses its 'gold card' status, do they lose their ability to participate with UnitedHealthcare patients?" said Andrew Albert, MD, gastroenterologist at Chicago Gastro, in the report. "Is there a set of guidelines they could share that rule in or rule out gold card eligibility?"
Another physician, Maria Abreu, MD, director of the Chron's and colitis center at the University of Miami Health System and president of the American Gastroenterological Association, voiced similar concerns. "[If] there’s something called a 'gold card,' it will be given to a select few," she said. "The majority, who take care of the majority of patients, won't be included."
3. According to the report, UHC said that it would use the data received through advance notification to make decisions about gold card eligibility. But Prateek Sharma, MD, professor of medicine at the University of Kansas School of Medicine in Kansas City and president of the American Society for Gastrointestinal Endoscopy, said that this seems contingent upon the participation of GIs in the advance notification process.
"ASGE does not know how many practices participated; therefore, we cannot anticipate how many GI practices will be eligible for UHC’s gold card program," he said. UHC will require a prior authorization approval rate of 92% or higher for two consecutive years to qualify for the gold card program, a requirement based on an unclear methodology, Dr. Sharma added.
4. Dr. Abreu also said that the eligibility threshold does not incentivize physicians to use their own medical judgment, which could harm patients who have more complex cases.
"This may work for practices that do primarily screening colonoscopy in patients 45 and older with no risk factors, but most people have some variant that keeps them from falling into a neat bucket. Also, we have so many guidelines on different things; some are old, some are new. Realistically, I don’t know how you parse through all that data," she said.
5. Gastroenterologists also told Gastroenterology that they desired more transparency in the design of the gold card program.
"We asked why they wanted to implement that policy, and they said there were gastroenterologists overutilizing services. We asked to see the data on this, and at first, they seemed to be willing to share that information," said Daniel Pambianco, MD, managing partner of Gastro Health in Charlottesville, Va. Dr. Pambianco also previously served as president of the American College of Gastroenterology.
According to the report, the UHC never shared the data it claimed showed GIs overutilization.
"Their sidestepping [of] these issues leads us to the conclusion that this is all about saving money. It has nothing to do with quality," Dr. Pambianco said.