GI docs say the payer is using AI to move large volumes of services through prior authorization.
Effective June 1, UnitedHealthcare will require prior authorization for nearly half (47%) of gastrointestinal (GI) endoscopies. The payer says the move is needed to curb costs related to alleged overuse of some GI procedures by physicians.
Physicians counter that the move is the latest evidence that UHC is tapping artificial intelligence to move large volume services through prior authorization.
The news does not sit well with GI docs, who believe that the prior authorization process is often abused by payers to create a hurdle for patients and providers to clear when filing claims and getting paid.
Bruce Hennessy, MD, a policy committee member of the American Society for Gastrointestinal Endoscopy, explains what his association believes is behind the expanded prior authorization (PA) mandate and what action physicians can take.
HL: Has UHC explained to you why it is imposing this new PA mandate?
Hennessy: UHC says geographic variation exists in the use of endoscopy services but refuses to share any further information about that variation. For example, we have asked whether the variation is confined to certain regions or certain codes within certain geographic areas. With more information, ASGE can engage in education and outreach to ensure that gastroenterologists are familiar with endoscopy guidelines and encourage them to participate in quality improvement activities.
Many of the CPT codes covered by the GI endoscopy prior authorization program are low volume and, therefore, could not be considered over-utilized. On several occasions, the GI societies have asked UHC to share its own de-identified, aggregate data that show recent evidence of over-utilization. Our requests have been denied. UHC instead has referred to studies they claim suggest over-utilization in GI endoscopy. To date, we have received no information from UHC that substantiates over-utilization for any GI endoscopic or capsule endoscopy procedure.
What GI and other specialties are experiencing is payers using artificial intelligence (AI) to move large volumes of services through prior authorization. With the help of AI, payers have little-to-no economic downside to increase the number of services, including low-cost services, that are subject to prior authorization. If payers are going to increase the burden of prior authorization on physicians and other providers, they should be required to be transparent about the need for prior authorization and the method of review on a service-by-service basis.
HL: Why do you object to this PA requirement?
Hennessy: 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. Further, UHC has not been transparent with evidence of over-utilization or geographic variation for the endoscopy services for which prior authorization will be required beginning June 1.
ASGE is on record supporting "Gold Card" programs which exempt physicians and other health care providers from a payer's prior authorization requirements if they meet certain eligibility requirements. For example, when a physician has high rates of prior authorization approvals for a particular service, including when that service is initially denied and approved on appeal.
In a March 9, 2023 news release, UHC promised to ease prior authorizations and announced that in early 2024 it would implement a national Gold Card program for certain provider groups, "eliminating prior authorization requirements for most procedures."
When ASGE asked UHC why it would not delay a new prior authorization program for GI endoscopy services and instead wait to utilize a Gold Card program to mitigate provider administrative burden, UHC representatives said the exact timing for the Gold Card program is unknown and that the Gold Card program and prior authorization for GI services are on "different trajectories."
UHC's decision to require prior authorization for nearly 50% of all endoscopy codes makes their public promise to reduce prior authorization burden on physician practices appear disingenuous at best.
HL: What specific patient health fallout would be expected with these new PA requirements?
Hennessy: The experience of ASGE members is that prior authorization delays patient access to recommended services. The expectation is patients who do not have a confirmed diagnosis of a GI disease or disorder but visit a gastroenterologist because they are experiencing abnormal signs or symptoms will suffer the most because physicians expect they will have to work harder to justify to UHC why the patient should receive an endoscopic procedure. Sometimes patient symptoms do not fit in an algorithm or may be limited in nature. Patients with limited English language proficiency might have difficulty articulating their symptoms. In these types of situations, a physician must interpret the symptoms and make the most appropriate recommendations regarding testing and treatment options. Those are the types of cases that are most likely to get spit out of an AI algorithm with a denial because the service requested does not match a diagnosis code.
Clinics that serve underserved areas may not have staffing to meet the demands of a new prior authorization program. At the same time UHC is implementing this program, which lacks any clear benefit to patients and that will require increased physician practice staffing, our health care system is experiencing a staffing crisis.
HL: Is there an average per patient cost/charge for endoscopies requiring PA, vs. endoscopies NOT requiring PA?
Hennessy: There is not a difference in the cost or charge to the patient for endoscopies requiring prior authorization versus those that do not. The physician practice incurs the staff cost associated with obtaining prior authorization — a cost that does not get passed onto the patient.
Insurance companies have no "skin in the game," especially with the use of AI when it comes to requiring prior authorization. We would like to see the tables turned and require payers to compensate physician practices for the cost associated with prior authorization when a service is initially denied and eventually approved on appeal.
Patients are increasingly encountering roadblocks to accessing recommended or prescribed care due to prior authorization and other utilization management tools that insurance companies claim are necessary to lower the cost of health care; yet, insurance premiums keep rising.
HL: What are the specifics of the "47%" of GI endoscopies requiring PA?
Hennessy: UHC is placing 61 endoscopy codes under prior authorization. These 61 codes represent roughly 47% of all endoscopy codes.
HL: How are they different from the (presumably) 53% of endoscopies that do NOT require PA?
Hennessy: The codes that will be subject to prior authorization are codes typically provided in the outpatient/ambulatory setting. The UHC prior authorization requirements are not applicable to services provided in the emergency room, urgent care centers, hospital observation units and the hospital inpatient setting.
The other 53% of codes include, but are not limited to advanced endoscopy procedures, such as ERCP and EUS, colorectal cancer screening, and capsule endoscopies codes.
HL: What action, if any, can your association take to oppose these PA requirements?
Hennessy: The ASGE has been working alongside the American College of Gastroenterology and the American Gastroenterological Association to oppose implementation of UHC's prior authorization program for endoscopy services on June 1. We have met with UHC and have presented them with a number of operational questions and have requested data that justifies this sweeping program. The request for data has been denied and many operational questions and concerns remain unanswered.
Earlier this month, ASGE and 171 other patient and provider organizations sent a letter to UHC asking the company to not implement the GI endoscopy prior authorization program, stating that it will limit access to care for vulnerable populations, delay diagnosis of colorectal cancer in younger populations, and needlessly increase physician and practice burden. There has been no response to the letter to date.
ASGE and the other GI societies are also meeting with congressional offices, and we are pleased the House Energy and Commerce Committee and the Senate Permanent Subcommittee on Investigations have launched inquiries into the use of AI for prior authorization by the nation's largest payers.
HL: What are you recommending your association members do in response to this new PA mandate?
Hennessy: ASGE and the other GI societies have asked their members to contact their state lawmakers with a request that they encourage state regulators to look into UHC's decision to move forward with the prior authorization program for endoscopy services with just 90 days advance notice and no transparency of data that support the implementation of such a sweeping program.
HealthLeaders reached out to UnitedHealthcare about the new PA requirements, and received this response:
"We have made no changes to our policy regarding screening colonoscopies for preventive care, and this policy does not impact screening colonoscopies. We are asking physicians to follow the guidelines and evidence-based practices developed by their own gastroenterology medical societies to help ensure our members have timely access to safe and clinically appropriate care. The physicians who will be most affected by this new policy are those who are not already following these evidence-based practices, which again, were developed by gastroenterology-related medical societies."
"Our electronic submission process allows for immediate approvals for physicians who have a history of following evidence-based guidelines for the requested procedure. For procedures that do not receive immediate approval, decisions are typically made within two business days after receipt of all required clinical information needed for our GI specialists to review the case – well within the average wait time to schedule a service included in this policy."
“To date, we have received no information from UHC that substantiates over-utilization for any GI endoscopic or capsule endoscopy procedure.”
Bruce Hennessy, MD, American Society for Gastrointestinal Endoscopy
John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.
Photo credit: Los Angeles, California, USA - 21 Jule 2019: Illustrative Editorial of UHC.COM website homepage. Shutterstock / II.studio
The codes that will be subject to PAs are typically provided in the outpatient/ambulatory setting.
The PAs are not applicable to services provided in the ER, urgent care centers, or hospital observation/ inpatient settings.
UHC says it hasn't changed its policy regarding screening colonoscopies for preventive care, and this policy does not affect screening colonoscopies.
UHC says it is asking physicians to follow the guidelines and evidence-based practices developed by their own gastroenterology medical societies.