On May 31, UnitedHealthcare reversed the proposed June 1 implementation of a controversial prior authorization process that would require gastroenterologists to submit requests for certain endoscopy procedures.
Instead, it implemented an advanced notification process that requires practices to submit certain patient data leading up to procedures. Practices that follow directives will have the opportunity to join a UHC "gold card" program in 2024.
Three major gastroenterological societies — the American College of Gastroenterology, the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy — have opposed UHC's prior authorization plans since they were released in March and were disappointed about the lack of communication from UHC.
Last week, UHC gave the major societies less than 24 hours of notice to discuss the alternative advanced notification process, asking for public support from the societies.
Lawrence Kim, MD, vice president of the AGA and gastroenterologist at South Denver Gastroenterology in Littleton, Colo., spoke with Becker's about the new advanced notification process and the difficulty of working with UHC throughout the proposed reform.
Question: Give us some background on how everything with UHC occurred.
Dr. Lawrence Kim: I was part of the call last Friday with UHC. The proposed prior authorization change has been in the works for months. AGA has been in constant communication with UHC asking them for more information, their rationale for institution, expressing concerns with regard to delaying patient care, potentially compromising health outcomes, especially in terms of worsening disparities, and of course the practice burden on physicians. This has been in the works for several months. UHC, by and large, has been completely unresponsive. Last Thursday, there was a very hasty invite to a call that was going to occur in 24 hours, which obviously was fairly difficult. We were able to pull together leadership from the American College of Gastroenterology, the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy to hear what they had to say. It was interesting to me. I am a little bit incredulous because they basically said we are going to rescind prior authorization plans, and instead are going to substitute this advanced notification program. They started the call by saying, "We're going to do this and we would love for the GI societies to publicly support the change." This was done with no warning, no information, nothing that was sent to anybody on the call or in advance of the call to even know what they were talking about. When we asked for details about what that involves, it was very nebulous. There was no clear process. They alluded to a portal that practices would have to log onto to supply clinical information about each case that was to be scheduled. That was about it actually. That's all they told us despite repeated efforts to pull more information about what the portal is and what types of information will be required. They kept referring us back to their existing prior authorization policies. They said something about 50 percent of prior authorization decisions are made through the patient portal online. The others go to peer-to-peer, where you have to wait for one of their representatives to contact you. That was kind of the gist of the call. Our response was, "We can't support a policy or program that we have no details about."' Certainly not without any reasonable amount of time to analyze and assess that information. We did ask again repeatedly. They basically said, "We are going to go ahead with something on June 1," and yesterday they did publicize this advance notice program. As far as I can tell, there is still no information in the materials that have been sent about how this operationally works. Another theme in our interactions with United is they don't provide data. United keeps speaking to overutilization of endoscopy services, and we pressed them on the call specifically about that and how they know there's overutilization. Ultimately, what they admitted was they don't have any information to support it. There have been studies which look at geographic variation in services, but UHC has nothing other than claims data. They are trying to get information, and I think that's the ulterior motive of doing this advanced notification process. It is getting information out of physicians medical records that's not readily available right now on an easy basis. They themselves have no data they're willing to share with us, and they don't have any such data supporting overutilization.
Q: Why do you think UHC pulled back on the proposed prior authorization changes at the last second?
LK: I can't speak for them. I don't know why they made the change and I don't know if it's actually a change. From my practice's point of view, I don't see a difference. Mostly because all prior authorizations do get approved. The frequency of denials, I don't have official data, but anecdotally, I can count on one hand the number of times I have gotten turned down in 25 years of practice. By and large, gastroenterologists do the right thing. There's guidelines we follow. Sometimes there are patients that guidelines are not directly applicable to, and we make the right decisions on how to address those patients.
Q: What is this advanced notification process going to be like for physicians?
LK: The advanced notification process is going to be difficult and onerous to comply with. For every single procedure that we do, except for screening colonoscopies, somebody on our staff is going to have to abstract clinical information from our electronic health records and provide that to United. That is going to be a significant volume of patients. United is one of the largest payers in most markets, and gastroenterology is a high volume specialty. Most GIs do many procedures in a day. To put it into perspective, each physician at our practice does about 1,100 procedures annually, and 25 percent are United patients. If you try to think about what UHC is trying to achieve here, they are trying to get information from medical records, which will not be contained in a discreet coding scenario. Codes generally don't have clinical detail, which is something UHC says they don't have. That's the problem with medical records in general. With the absence of any structured way to get that information, it's reading through medical records to get that information.
Healthcare researchers spend their whole career trying to do this. Now, we're going to be putting this onus on physicians and staff to do this. Is a physician going to do this? There aren't enough hours in the day for that to happen. Can practices afford to get nurses or clinical staff to do it? Probably most can't. This is going to fall on clerical people and there's going to be a lot of mistakes. This data will be highly inaccurate. It's not going to answer the questions United is trying to answer. There was an opportunity lost here for UHC to work constructively with the major GI societies to figure out variation in practice and why that's occurring and to educate and solve a problem in a constructive faction. Which is why societies like AGA exist. Instead, what you're going to have is an onerous process that is still going to delay care to patients and still present barriers to care. What I'm concerned about is underutilization. UHC speaks to this a little bit in the bulletin they sent out, that they will see if there's underutilization. I'm not sure how they are going to tell that.
Q: How will it impact patients, if at all?
LK: I don't know. It hasn't actually been implemented yet, but what I do know is once it is in place, some person on my staff is going to have to try to figure out how to enter all this information before scheduling a procedure. Trying to go through that process for the number of patients we see in a day is going to take a significant amount of time and effort on behalf of the practice.
For practices that do not participate, you don't get a shot at being a "United gold card member," but they haven't laid out what that means. That's the carrot UHC is dangling. If you somehow demonstrate that you are an acceptable provider, by their criterion, we will let you into this gold card program. But there's no real information about how you're going to be eligible for that, or what that even means. What we do know is they're not abandoning prior authorization, they're simply postponing it. Which flies in the face of everything they've been saying. They've been talking publicly about how they are moving away from prior authorization. With GI, this is going to be a major expansion of prior authorization, which we basically know just doesn't work. It delays care, harms outcomes and endangers patients in many situations.