UHC Requires Prior Authorization Colonoscopy

[somarco]

The change, which the health insurer will implement on June 1, means that any United member seeking surveillance and diagnostic colonoscopies to detect cancer will first need approval from United — or else have to pay out of pocket.

"It was stunning," said Dayna Early, a gastroenterologist at Washington University in St. Louis and chair of the American College of Gastroenterology's board of governors. "It applies to everything we do except screening colonoscopy" — routine procedures meant to detect cancer in low-risk, healthy members of the general population between the ages of 45 and 74. "One of the most frustrating things is we don't understand why they are doing this."

Physicians say that requiring prior authorization will make it more difficult for patients to get endoscopic procedures, particularly cancer diagnostic and surveillance procedures, in a timely fashion. These make up roughly half of the procedures that gastroenterologists perform.

[EXTERNAL LINK] - 'Stunning' change to United's colonoscopy coverage roils physicians and patients

 

[Fisher]

The article doesn't state if this applies to ALL UHC plans, just ACA plans, just MAPD plans, etc. That would be handy info to know.

 

[somarco]

The article doesn't state if this applies to ALL UHC plans, just ACA plans, just MAPD plans, etc. That would be handy info to know.

I searched before posting. Can't say if it is for ALL UHC managed care plans or not . . . group, individual, Medicare, Medicaid(?) . . . but by not delineating which plans the assumption is it applies to all.

At least that is my interpretation.

It would not apply to OM + Medigap . . .

However, word is out . . .

https://www.ccalliance.org/blog/get...hcare-require-prior-authorization-colonoscopy

https://www.uhcprovider.com/content...rior-auth/Prior-Auth-Gastroenterology-FAQ.pdf

[EXTERNAL LINK] - New requirements for gastroenterology services | UHCprovider.com

What IS important is that UHC is doing this while other carriers are not

 

[policywunk]

The article doesn't state if this applies to ALL UHC plans, just ACA plans, just MAPD plans, etc. That would be handy info to know.

don't let the facts get in the way of a good story.....

 

[somarco]

UPDATE . . .

United hasn't provided details on how physicians will code screening colonoscopies, information that's necessary for them to get reimbursed for the procedures. Also, when a screening colonoscopy does find polyps or cancer, it must be coded differently — potentially as a procedure that does require prior authorization, Mehta said. That makes it unclear how exactly physicians should proceed, how retroactive authorizations would work, or if the patient could end up stuck with the bill.

"We don't know what the situation is when they come in, and we have to code whatever we see," Mehta said. "That's what's confusing — what prior authorization covers or doesn't. That puts us in a precarious situation, and it's not clear how United has rolled it out to differentiate that."

United told the physicians that its data was proprietary and could not be shared. United also told gastroenterology societies that "there is no longer a desire to meet," according to the ACG.

UnitedHealthcare did not agree to an on-the-record interview with STAT.


[EXTERNAL LINK] - 'Stunning' change to United's colonoscopy coverage roils physicians and patients

Note, this applies to a diagnostic and surveillance colonoscopy, not routine annual physical/wellness exams. The PA only applies when the physician suspects a problem and requires additional screening.

 

[Duaine]

For dates of service beginning on or after June 1, 2023, you'll be required to obtain prior authorization for gastroenterology endoscopy services for UnitedHealthcare commercial plan members, in accordance with the terms of the member's benefit plan.

 

[Packerland]

This is for employer and individual plans right now- and what this is trying to do is put a Prior auth in place for those colonoscopies that doctors are ordering when they don't align with the national standard. Ex: if someone falls into the category of getting a colonoscopy every 5 years but the doctor says come back in 4 years for another colonoscopy. Then we need a prior authorization to know the medical reasons why they are not suggesting the medical national standard 4 vs 5 years.
Hope that helps.

This does not apply to Medicare ...at least not now.
This is a good thing

 

[Yagents]

This is for employer and individual plans right now- and what this is trying to do is put a Prior auth in place for those colonoscopies that doctors are ordering when they don't align with the national standard. Ex: if someone falls into the category of getting a colonoscopy every 5 years but the doctor says come back in 4 years for another colonoscopy. Then we need a prior authorization to know the medical reasons why they are not suggesting the medical national standard 4 vs 5 years.
Hope that helps.

This does not apply to Medicare ...at least not now.
This is a good thing

I thought u said before that PA was a good thing in order to cut costs and avoid unnecessary claims? Or was that midlevel?

 

[Packerland]

I thought u said before that PA was a good thing in order to cut costs and avoid unnecessary claims? Or was that midlevel?

PA is a good thing to control cost if done in a timely manner max time frame between 2 and 5 days.

What is your problem with having doctors to adhere to national standards... if the national standards for a procedure is 5 years yet the doctor says 4 years why shouldn't he have to justify it?

 

[Yagents]

Maybe family colon cancer history, or maybe a belly ache. Or shutting out of her ass. It should be up to dr