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.
Dr Barbara H. Jung
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, AGA president.
“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) endoscopy 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, they’ve stated, 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, they have 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.
The advance notification policy comes despite immense pressure from physicians, patients, lawmakers, and regulators to crack down on prior authorization policies. “AGA has expressed our 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,” Jung said.
How Advance Notification Works
Beginning June 1, providers were asked to provide advance notification for nonscreening GI endoscopy procedures that include: esophagogastroduodenoscopy, capsule endoscopy, diagnostic colonoscopy and surveillance colonoscopy. The notification can be made by phone (866-889-8054) or through a UHC online portal at UHCprovider.com.
The AGA has said that some GI practices have found the portal to be confusing and it lacks a standard software application raising concerns for high error rates.
Advance notification applies to patients who have UHC commercial plans, including UnitedHealthcare, UnitedHealthcare Plan of the River Valley, Neighborhood Health Partnership, UnitedHealthcare Level Funded, and UnitedHealthcare Oxford Health Plans in all states, except Rhode Island, Kentucky, and New Mexico.
Providers who opt out of participating in advance notification will not be eligible to participate in the Gold Card program in 2024, which will essentially allow providers to order most GI endoscopy procedures, except for screening colonoscopy, without prior authorization. However, UHC has not released any information about how it will implement its planned Gold Card prior authorization program or how many providers will be accepted into the program.
UHC has assured providers they will not issue medical necessity denials through this process, but they may ask providers to participate in a “comprehensive peer-to-peer discussion with a board-certified gastroenterologist around clinical guidelines.”
The fear for practices is that advance notification will be an onerous process adding burdensome paperwork that practices are not equipped to manage. UHC is the largest health insurer in the country representing 46% of the total market.
Lawrence Kim, MD, AGAF, vice president of AGA and a gastroenterologist practicing in Denver said that each physician in his practice does over 1,000 procedures annually and 25% of their patients carry UHC.
“We are currently completing 30-40 notifications a day, requiring two staff members to comply with this program. UHC is not asking for any clinical information, just procedure and diagnosis codes, and in some cases site of service. Therefore, the advance notification program as it stands will not provide UHC with any additional information beyond what they already have through claims data. This highlights the strain these requirements are putting on providers and practices for repetitive data,” he said.
For more details about UHC’s advance notification program, UHC has prepared this FAQ. To learn more about AGA’s advocacy, visit www.gastro.org/UHC.
This story originally appeared on MDedge.com, part of the Medscape Professional Network.
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