Digital Debut

ASCA Opposes Upcoming UnitedHealthcare Prior Authorization Policy

ASCs will have to meet the requirements this summer

BY ALEX TAIRA | MAY 2023

Beginning June 1, 2023, insurer UnitedHealthcare (UHC) will require providers to seek authorization before performing almost all upper gastrointestinal (GI) endoscopy, colonoscopy and capsule endoscopy procedures. This prior authorization policy includes four of the top five codes by volume performed in ASCs and would drastically affect the operations of many surgery centers that perform GI procedures. ASCA, in close collaboration with the main specialty societies representing the interests of GI clinicians, has been working to stop or delay the policy from taking effect.

UHC is a subsidiary of UnitedHealth Group that owns Optum. UHC is one of the largest, if not the largest, health insurers in the US reporting almost $250 billion in revenue in 2022 alone.

Background

The concept of prior authorization, or requiring a medical necessity review prior to procedure performance, is not new. The use of prior authorization policies to control costs became prevalent in the 1980s, when employers became involved in health insurance via employer-sponsored health plans. When deployed appropriately, prior authorization—also known as precertification or prior approval—can be a method to reduce overutilization of medical services or to enforce certain standards of care. However, policies must have considerable clinical and data-backed evidence that can clearly show overutilization or deviation from standards of care to warrant adding an often burdensome step into the patient-provider relationship.

UnitedHealthcare Policy

According to UHC, all commercial plan members will be required to obtain prior authorization for GI endoscopy services for procedures beginning June 1. A total of 61 codes will be affected by the policy, including numerous codes performed in high volume in ASCs like CPT code 45380 (colonoscopy, flexible; with biopsy, single or multiple). Screening colonoscopies are not directly included in the policy and will apply only to outpatient settings, such as hospitals, ASCs and physician offices.

In the frequently asked questions document, UHC cites research that shows overutilization of invasive non-screening colonoscopy, esophagogastroduodenoscopy (EGD) and capsule endoscopy procedures that is passing unwarranted costs to patients. However, thus far UHC has declined to share any of the research or internal data showing this overutilization.

Effective June 1, providers will be required to submit prior authorization requests through the UHC provider portal, after which UHC will respond with a coverage determination or request for additional patient information. Although the prior authorization process is supposed to hinge on medical necessity, the information that providers must supply is mostly demographic in nature (see required information below). UHC does state that providers should be prepared to supply additional clinical information such as patient histories, labs and prior treatment regimens.

Data required from providers for authorization.

Advocacy Actions

On March 16, 2023, GI-focused specialty societies held a call with UHC to discuss the impending policy. UHC again cited trends in non-screening colonoscopies and upper GI procedures but declined to share specific literature or market variation data. It also declined to answer what percentage or volume increase in procedures generally triggers a need for prior authorization. The UHC provider portal, which will be used for prior authorization requests, will be combined with portals used for existing site-of-service programs, and the company estimates a two-day turnaround for prior authorizations on average. Despite requests from the American Gastroenterological Association (AGA) and other specialty societies to delay the policy, UHC has thus far remained steadfast on the June 1 launch date.

In early April, ASCA staff began reaching out to AGA, the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy to see how ASCA can help to push back against the policy. AGA had already organized a letter campaign through which individual physicians could submit letters to the UnitedHealth Group chief executive officer (CEO) asking to rescind the policy and had more than 600 letter submissions by mid-April. On April 14, ASCA and 24 other organizations sent a letter to UnitedHealth Group CEO Andrew Witty asking him to stop the policy. The association sent an individual letter on behalf of the ASC community on April 17 and signed on to another, broader sign-on letter sent on May 8 that more clearly delineates the arguments against the policy, namely its effect on screening colonoscopies, increases to physician burden, lack of evidence of overutilization and limiting effect on patient care. ASCA will continue to collaborate with the GI specialty society partners and patient advocacy organizations to delay or stop the implementation of the policy.

For more information, write Alex Taira.