Healthcare Organizations Oppose UHC’s GI Prior Authorization Program

More than 170 healthcare organizations have urged UnitedHealthcare not to implement its gastrointestinal (GI) endoscopy prior authorization program, stating that it will hurt patients and limit access to care.

In a letter to Andrew Witty, chief executive officer of UnitedHealth Group, the organizations said the program could delay diagnosis of colorectal cancer in younger populations and increase physician and practice burden.

Notable signatories included MGMA, the American College of Physicians, and the American Gastroenterological Association (AGA).

Although the prior authorization program for GI endoscopy excludes screening colonoscopy, the policy may impact patients’ willingness to undergo medically recommended colonoscopy exams after polyps or cancers are removed, according to the letter. Additionally, the organizations said that UnitedHealthcare has not provided instructions on how to code screening colonoscopy in a way that avoids prior authorization.

The policy may also exacerbate care disparities among vulnerable populations who currently experience access issues.

UnitedHealthcare’s program will lead to care delays for high-risk individuals in particular as the payer will require patients to receive prior authorization approval for treatment even when a clinician has deemed them at high risk for colorectal cancer, the organizations said.

The program will require prior authorization for most GI endoscopic procedures, including esophagoscopy, a low-volume procedure used to treat patients at risk for esophageal candidiasis and reflux esophagitis with stricture. Many of the CPT codes covered by the GI endoscopy prior authorization program are low-volume and not considered overutilized, the letter stated.

The organizations also highlighted how the prior authorization policy will increase unnecessary administrative burden for providers.

“Because endoscopists often do not know exactly what procedure(s) they will be providing during an endoscopy, UHC clinician representatives have told us that endoscopists will need to request prior authorization for the base code (e.g., 43235 for EGD and 45378 for colonoscopy),” the letter stated.

“Therefore, from a practice operations standpoint, every upper and lower endoscopic and capsule endoscopy procedure will inadvertently require prior authorization, not just the 61 codes listed in UHC’s GI Endoscopy Procedures list.”

Physician burden from prior authorization is already high, with the average medical practice completing 45 prior authorizations per week per physician and dedicating almost two business days per week to the process, according to data from the American Medical Association (AMA).

“UHC’s short-sighted GI endoscopy prior authorization program has not been well designed, will result in delays for medically necessary care for patients, adds unnecessary paperwork burden to physicians and their staff, and may violate CCIIO recommendations. For these reasons, we urge you not to implement the GI endoscopy prior authorization program,” the groups concluded.