After discussions with AHA, UnitedHealthcare alters GI policy to preempt care delays and claims denials

Following discussions between the American Hospital Association and United Healthcare, the insurer announced May 31 a refocused gastroenterology 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. The GI policy, which pertains to certain non-screening endoscopy and colonoscopy services, goes into effect today, June 1.

UHC will instead implement a 7-month, or potentially longer, 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. This data will be applied to UHC's gold-carding program, beginning sometime in 2024, to exempt physicians that are routinely aligned with the insurer's guidelines. The insurer has yet to determine any additional controls that will be placed on non-gold-carded clinicians at the end of the pilot.

The standard data required in advance of care are member information, requested procedure and diagnosis, referring provider information and rendering provider information and site of service. Other potentially relevant details of a patient's condition or medical history, including the indication for the procedure and the results of prior testing, may also be requested when necessary.

The data submitted will be reviewed by a board-certified gastroenterologist for adherence with applicable clinical guidelines and used as an opportunity to engage in physician education where appropriate. The focus on provider education should diminish the risk of patient access issues by removing the need for preauthorization in advance of the service and the accompanying risk of coverage or payment denials. The AHA agrees 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 GI policy on provider education to address member concerns about potential care denials and additional preauthorization requirements," said Rick Pollack, AHA's president and CEO. "We plan to collaborate with UHC to help ensure it meets its goal of providing meaningful education for providers while proactively addressing these concerns."