The Texas Medical Association joined roughly 200 national and state medical specialty societies, patient organizations, foundations, and physician groups in a widespread call urging UnitedHealthcare (UHC) to halt its nationwide policy requiring prior authorization for gastroenterology endoscopy services that take place on or after June 1.
In a letter sent to UHC earlier this month, medicine asserted the policy puts cost controls ahead of patient care and “will harm patients, limit access to care for vulnerable populations, delay diagnosis of colorectal cancer in younger populations, and needlessly increase physician and practice burden.”
If UHC goes forward with the policy, the following patient services will require separate prior authorization even if performed at the same time as each other:
- Upper endoscopies, or esophagogastroduodenoscopies (EGDs),
- Capsule endoscopies, and
- Diagnostic and surveillance colonoscopies.
In Texas, the policy will affect all UHC commercial plan members. Routine screening colonoscopy procedures will not be included under the plan.
UHC pointed to “overutilization of invasive non-screening (surveillance and diagnostic) colonoscopies, EGD, and capsule endoscopy procedures in certain situations that expose patients to unnecessary risk and costs” as reason for the change in its FAQ sheet.
Medicine challenged that assertion, saying it lacked sufficient data to back it up and “many of the CPT codes covered by the GI endoscopy prior authorization program are low volume and could not be considered overutilized.” On the contrary, physicians continue to report that prior authorization delays cause patients to wait longer for necessary medical care, among other problems.
As “colorectal cancer is a leading cause of cancer death among people under 50 in the United States,” per the National Cancer Institute, UHC’s prior authorization policy could have a “chilling effect on patients’ willingness to undergo medically recommended subsequent colonoscopy examinations,” medicine wrote.
TMA continues to meet with each of the major insurance companies to discuss the administrative burdens the UHC policy and others may cause. TMA is concerned about the contribution of such burdens to physician burnout, and the impact of payment delays on access to care.
In the meantime, physicians can submit a prior authorization request to UHC by:
- Using the Prior Authorization and Notification tool on UHCprovider.com through the UnitedHealthcare Provider Portal; or
- Calling UHC at 866-889-8054 (Oxford 877-773-2884), Monday through Friday, 7 am to 7 pm in all time zones.
The prior authorization request will be valid for 90 calendar days, which begins on the date it’s approved.
To share questions or concerns, call TMA’s Billing and Coding hotline at (512) 370-1414 to speak directly with one of TMA’s certified coders, or visit TMA’s Reimbursement, Review, and Resolution Service page.
For educational resources, visit TMA’s Education Center to view courses on Billing, Coding, and Payers.
Alisa Pierce
Reporter, Division of Communications and Marketing
(512) 370-1469