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 big for almost all gastroenterology procedures, together with diagnostic and surveillance colonoscopy, or probably face paying out of pocket, would have gone into impact on June 1.
As a substitute, the corporate is adopting a distinct 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 outcome within the denial of look after scientific causes or for failure to inform,” a UnitedHealthcare spokesperson advised 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 places of work and since this system nonetheless feels involuntary, mentioned Barbara Jung, the president of the American Gastroenterology Affiliation. Docs who don’t present the advance notification will probably be disqualified from United’s “gold card” program, a standing that permits medical doctors to bypass all prior authorizations.
“It was disappointing,” Jung mentioned. “It’s totally different from prior authorization as a result of there gained’t be any denials as a part of this, however we don’t have numerous particulars.”
In a gathering that the doctor teams had with United final week, Jung mentioned that gastroenterologists had, as soon as once more, requested United for information on over-utilization and nonadherence to scientific tips. “It turned clear they’d no such information,” Jung mentioned. “And this advance notification was floated, and it turned clear that it’s a information gathering device. That is actually to assist inform a future prior authorization proposal, so it looks like a pre-rollout of prior authorization.”
An announcement from United confirmed that the advance notification program is designed to gather information, though United mentioned it was to raised perceive which physicians will probably be eligible for the “gold card” program.
The transfer away from prior authorization and towards advance notification is a step in the proper path, mentioned 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 boundaries to care,” Smith mentioned. “We’re more than happy with the step that United is taking with this system.”
That’s as a result of superior notification ought to neither create new boundaries for sufferers getting lifesaving procedures like colonoscopies and different GI procedures nor ought to it stop physicians from getting paid, Smith mentioned. She’s additionally hopeful that the gold carding program will assist alleviate among the administrative burden that prior authorization insurance policies have on physicians generally, though, “we have now seen thus far that they’re arduous to arrange. They require information and knowledge to design,” Smith mentioned.
Jung mentioned that whereas amassing information could also be a step in the proper path, United’s advance notification program was unlikely to yield helpful information on over-utilization of gastroenterology procedures. United hasn’t supplied a standardized manner for physicians to supply the wanted data, she mentioned. With no clear information gathering and analysis plan, it could be troublesome to match data from one clinic to the following — you won’t know when you’re evaluating apples to apples.
“Our well being companies researchers had no confidence in such a information gathering having the ability to yield a significant database to reply their query – if that query is over-utilization,” Jung mentioned.
United additionally didn’t point out there have been any plans to share information gathered from the advance notification program with researchers or gastroenterology societies, Jung mentioned.