After weeks of protest from doctor organizations and sufferers, UnitedHealthcare has put a controversial new prior authorization coverage for gastroenterology procedures on maintain. The coverage, which requires physicians and sufferers to get approval from the insurance coverage large for practically all gastroenterology procedures together with diagnostic and surveillance colonoscopy or doubtlessly face paying out of pocket, would have gone into impact on June 1.
As a substitute, the corporate is adopting a unique coverage that it calls “superior notification,” requiring physicians to let United know they’ll be performing sure gastrointestinal procedures and supply data resembling why it’s wanted and the affected person’s medical historical past. “This Advance Notification is not going to end result within the denial of look after scientific causes or for failure to inform,” a UnitedHealthcare spokesperson instructed STAT in an e-mail.
Nonetheless, the frustration from gastroenterology societies and the general public outcry following STAT’s reporting of the problem has not totally abated. That’s partly as a result of the advance notification will nonetheless burden doctor workplaces and since this system nonetheless feels involuntary, stated Barbara Jung, the president of the American Gastroenterology Affiliation. Docs who don’t present the advance notification will likely be disqualified from United’s “gold card” program, a standing that permits docs to bypass all prior authorizations.
“It was disappointing,” Jung stated. “It’s totally different from prior authorization as a result of there received’t be any denials as a part of this, however we don’t have lots of particulars.”
In a gathering that the doctor teams had with United final week, Jung stated that gastroenterologists had, as soon as once more, requested United for knowledge on overutilization and nonadherence to scientific pointers. “It grew to become clear they’d no such knowledge,” Jung stated. “And this advance notification was floated, and it grew to become clear that it’s a knowledge gathering device. That is actually to assist inform a future prior authorization proposal, so it looks like a pre-rollout of prior authorization.”
A press release from United confirmed that the advance notification program is designed to gather knowledge, though United stated it was to higher perceive which physicians will likely be eligible for the “gold card” program.
The transfer away from prior authorization and in the direction of advance notification is a step in the best path, stated Molly Smith, a vice chairman of public coverage on the American Hospitals Affiliation. “We positively had considerations concerning the prior authorization about sure GI procedures. Prior authorization has been proven to create obstacles to care,” Smith stated. “We’re very happy with the step that United is taking with this system.”
That’s as a result of superior notification ought to neither create new obstacles for sufferers getting life-saving procedures like colonoscopies and different GI procedures nor ought to it forestall physicians from getting paid, Smith stated. She’s additionally hopeful that the gold carding program will assist alleviate a few of the administrative burden that prior authorization insurance policies have on physicians normally, though, “we’ve got seen up to now that they’re exhausting to arrange. They require knowledge and knowledge to design,” Smith stated.
Jung stated that whereas amassing knowledge could also be a step in the best path, United’s advance notification program was unlikely to yield helpful knowledge on overutilization of gastroenterology procedures. United hasn’t supplied a standardized approach for physicians to offer the wanted data, she stated. With no clear knowledge gathering and analysis plan, it could be troublesome to match data from one clinic to the subsequent – you may not know when you’re evaluating apples to apples.
“Our well being companies researchers had no confidence in such a knowledge gathering having the ability to yield a significant database to reply their query – if that query is overutilization,” Jung stated.
United additionally didn’t point out there have been any plans to share knowledge gathered from the advance notification program with researchers or gastroenterology societies, Jung stated.
