Yet Another Payer Backtracks on Mandate Amid Provider Pushback

UHC is pulling back on its controversial prior authorization mandate.

UHC was set to require added prior authorizations for nearly half (47%) of gastrointestinal endoscopies starting June 1, saying more prior authorizations were needed to curb costs related to alleged overuse of some of these procedures by physicians.

After intense pushback from large medical associations, UHC is pulling back.

Before UHC reversed course, Bruce Hennessy, MD, a policy committee member of the American Society for Gastrointestinal Endoscopy, spoke to HealthLeaders about this mandate, and shared the societies concerns.

“Physicians are overwhelmed with prior authorization requirements. The process of prior authorization is not transparent and denials and appeals for medically necessary services oftentimes result in patient harm,” Hennessy said.

Further, UHC was not transparent with evidence of over-utilization or geographic variation for the endoscopy services for which prior authorization would have been required, he said.

The day before the mandate was set to go live, UHC announced a refocused policy that relies on additional provider education rather than prior authorizations to address the insurer’s concerns about possible overutilization.

The refocused policy avoids potential care denials for patients, particularly vulnerable patients, and will not impact the coverage and payment of claims for these services, UHC said.

According to the payer, it will instead implement a pilot program to collect data that substitutes notification and submission of standard clinical data when services are delivered for prior authorization, removing the risk of potential care delays and claim denials.

The American Hospital Association (AHA), who was also strongly opposed to the mandate, said this refocused policy is a better approach and encourages UHC to implement the program in the most efficient way possible to avoid any duplication in the clinical information requested. 

“We appreciate UHC refocusing its policy on provider education to address member concerns about potential care denials and additional preauthorization requirements,” said Rick Pollack, AHA’s president and CEO in a release. “We plan to collaborate with UHC to help ensure it meets its goal of providing meaningful education for providers while proactively addressing these concerns.”

This win for providers is similar to a recent change in policy we saw with Cigna.

Just days before it was to take effect, Cigna announced it would delay implementation of a strict new policy requiring submission of office notes with all claims including certain codes billed in conjunction with modifier -25.

The addition of new, burdensome mandates by payers is not new, but it has certainly been further straining the payer/provider relationship. Luckily, it seems that with some pushback from providers, concerns are being heard and changes are being implemented.