'We should not participate in gathering data for UnitedHealthcare': Why 1 gastroenterologist opposes UHC's new GI advanced notification plan

In March, insurer UnitedHealthcare announced changes to prior authorization for certain GI procedures. The night before changes were to take effect on June 1, UHC reversed the plan, opting instead for an advanced notification alternative.

The new plan requires gastroenterologists to submit certain patient data, which it will collect for future use in a "gold card" program, set to launch in 2024. 

Gastroenterologist Linda Lee, MD, medical director of endoscopy at Boston-based Brigham and Women's Hospital and associate professor of medicine at Boston's Harvard Medical School, says that gastroenterologists should be leery of UHC's prior authorization alternative. 

Question: Why do you think that UHC pulled back on its prior authorization plan at the last second? 

Dr. Linda Lee: Since the announcement of the incredibly flawed and dangerous prior authorization plan by UHC, there was an uproar amongst GI physicians across the country which thankfully led to a united, concerted effort amongst the various GI societies to oppose this proposed change and discuss with UHC all the reasons why this would be deleterious most importantly to the patient, but also to the providers and their staff. We need much more of this type of advocacy work by the GI societies to protect our patients, as well as ourselves.

Q: Do you think this new proposal is better, worse or equally bad for GI patients? 

LL: While UHC has stated they will not "issue medical necessity denials for procedures that are not aligned with clinical evidence" during 2023 while they "collect the data received through advance notification to accelerate gold carding for eligible physician groups in early 2024," what exactly does this mean? Why does UHC need this data? What will they be doing with this data? What data will they require from physician groups? This, again, means time wasted by staff gathering "data" for an insurance company, which will take the medical staff away from spending this valuable time on actually helping our patients. Until we get more clarification about this plan, we should not participate in gathering data for UHC.

UHC also provided data without references that up to one-third of upper GI procedures and nearly one-half of non-screening colonoscopies performed are not consistent with guidelines. Even if this is accurate data, what an insurance company doesn't seem to appreciate is that guidelines are exactly that. They are meant to guide clinicians, but are not absolute immutable rules. Every patient is unique and different with nuances that only a clinician caring for the patient can fully appreciate. Also, they ask that for urgent procedures, medical staff call UHC within two business days of the procedure to provide justification for why the procedure was needed and why someone couldn't call UHC during normal business hours. By definition, if a procedure was urgent, shouldn't it be self-evident as to why it was being performed, and why must the clinician's staff waste time to justify this to an insurance company? Will UHC provide us with the staff to enter all this data and make all these calls to them? What a waste of money and resources that should be better directed to actually take care of our patients.

To summarize, UHC has backed down from their insurance-company-centered plan to require prior authorizations, but has provided few details about this "gold card program," which unfortunately seems to require the same waste of our resources and time to provide UHC with data. Why do physicians need to prove to insurance companies that we are worthy of their covering our procedures when it really should be the other way around where insurance companies must be held accountable for their actions that are frequently deleterious to patients’ well-being and mainly focused on their bottom line? Why aren't our legislators mandating this type of accountability and doing away with most prior authorizations? Instead, too many line their own pockets with inducements from insurance lobbyists and back down from legislation that would actually protect patients and physicians from this ongoing encroachment by insurance companies into a physician's clinical practice, which only leads to increased cost to the healthcare system, more administrative bloat, and decreased timely and efficient care of our patients.   

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