In March, insurer UnitedHealthcare announced changes to its prior authorization rules for certain GI procedures that were set to go into effect June 1. The night before changes were supposed to take effect, UHC reversed its plans, opting instead for a "gold card" program.
Earlier in the week, UHC requested a meeting with key GI societies, who opposed the idea of a gold card program, saying the implementation was too hasty.
"UHC was asking for a hastily organized meeting with AGA and the other GI societies to discuss the outlines of a poorly defined advance notification program," the American Gastroenterological Association said in a May 31 statement sent to Becker's. "Since then, AGA has received extremely limited details about this newly proposed program — aside from a proposed framework that would mandate physicians to provide even more data on top of the current burdensome paperwork requirements. This program is a temporary patch — patients will not be denied care tomorrow, but the downstream effects of the program could be as bad or worse for patient access."
UHC's new plan, which goes into effect June 1, requires providers to provide advance notification in lieu of prior authorization for gastroenterology endoscopy services for UnitedHealthcare commercial plan members. These changes do not include colonoscopy procedures, according to UHC's website.
"The advance notification process for non-screening GI procedures supports our efforts to ensure access to safe and affordable care. During 2023, we will use the data received through advance notification to accelerate gold carding for eligible physician groups in early 2024," UHC's website says.
"UHC has not provided any data that there is a problem with overutilization of endoscopic procedures. In exchange for collection of all this data, we have no clear sense that a future prior authorization program will be targeted to endoscopic indications that are indeed overutilized. This program will ultimately adversely affect patient care in the gold card program," the AGA told Becker's.
Last week, a spokesperson from UnitedHealthcare told Becker's that changes to GI prior authorization are meant to improve patient safety and prevent procedure overutilization.
"To provide an opportunity for physician education and to allow us to collect more data on which physicians should be eligible for our previously announced 2024 gold card program, effective immediately, we will be implementing an advance notification process, rather than prior authorization, for non-screening and non-emergent GI procedures. This advance notification will not result in the denial of care for clinical reasons or for failure to notify and will help educate physicians who are not following clinical best practices. Provider groups who do not submit advance notification during this period will not be eligible for the UnitedHealthcare Gold Card program," UHC told Becker's in a June 1 email.