‘Stunning’ change to United’s colonoscopy coverage roils physicians and patients

When gastroenterologists learned in March that UnitedHealthcare plans to barricade many colonoscopies behind a controversial and complicated process known as prior authorization, their emotions cycled rapidly between fear, shock, and outrage.

The change, which the health insurer will implement on June 1, means that any United member seeking surveillance and diagnostic colonoscopies to detect cancer will first need approval from United — or else have to pay out of pocket.

“It was stunning,” said Dayna Early, a gastroenterologist at Washington University in St. Louis and chair of the American College of Gastroenterology’s board of governors. “It applies to everything we do except screening colonoscopy” — routine procedures meant to detect cancer in low-risk, healthy members of the general population between the ages of 45 and 74. “One of the most frustrating things is we don’t understand why they are doing this.”

Physicians say that requiring prior authorization will make it more difficult for patients to get endoscopic procedures, particularly cancer diagnostic and surveillance procedures, in a timely fashion. These make up roughly half of the procedures that gastroenterologists perform.

UnitedHealthcare has said that prior authorizations in general should be completed within two days, but clinicians interviewed by STAT said that’s rarely the case.

“People with concerning symptoms for cancer, suddenly they may have to wait potentially weeks or months or longer for this to get approved,” said Folasade May, a gastroenterologist at the University of California, Los Angeles. “It may not even get approved.”

For those patients who have undiagnosed cancer, a months-long delay in diagnosis can be disastrous, May said. Some colorectal cancers can be slow-growing, but others can be fatally aggressive without early intervention. “I don’t want to see colorectal cancer patients saying, ‘I started seeing symptoms 10 months ago, but I had to get prior auth, and now I have stage 4 disease,’” she said.

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The policy change also struck gastroenterologists as tone-deaf and offensive, as the health insurer followed the March announcement with a press release that month declaring that they would reduce prior authorizations across the board by 20%.

“They made this announcement in March, during colorectal cancer awareness month,” May said. “Then they put out all this press that they will simplify the health experience for consumers and providers by eliminating other prior auth. That was an insensitive thing they did.” She added: “People are like, they’re trying to do better, but this one program will potentially affect millions of Americans.”

UnitedHealthcare did not provide a comment when asked about the timing of the announcement. In an emailed statement to STAT about the reasons for the policy change, United said, “Multiple clinical studies have shown significant overutilization or unnecessary use of non-screening gastroenterology endoscopy procedures which may expose our members to unnecessary medical risks and additional out of pocket costs.”

The statement also added that “the physicians who’ll be most affected by this new policy are those who’re not already following these evidence-based practices.”

But physicians say they’ve been stonewalled in their efforts to understand more about United’s purported evidence that too many doctors are ordering unnecessary colonoscopies.

“We’re frustrated,” said Shivan Mehta, a gastroenterologist at the University of Pennsylvania and an American Gastroenterological Association member who has attended meetings with the insurer about the new prior authorization requirements. “Mainly because we want to work together. I appreciate that they meet with us. They’re perfectly cordial, but I don’t know if they’re listening to us.”

The costs and confusion of prior authorization

In theory, prior authorization is meant to be a check on overspending in the health care system. Insurers say that by requiring doctors to show that a procedure or medicine is clinically necessary before they agree to cover it, they can prevent overprescribing of medicine or over-performing of procedures that patients may not actually need, or nudge providers towards more cost-effective alternatives.

In reality, clinicians and patients have long attested that prior authorization can be a complicated and arcane process involving insurance employees without medical training or specific expertise, often resulting in delays and denials of necessary care. More than one-third of physicians said that prior authorization had led to a “serious adverse event” for patients in a 2022 American Medical Association survey, while 91% said that prior authorization had a “somewhat or significant negative impact on patients’ clinical outcomes.”

Prior authorization is also a notoriously frustrating and costly process for all involved. Once a doctor knows that a patient needs a prior authorization for a procedure or medication, they or another employee need to file paperwork with the patient’s insurance company to get the authorization.

“From a practice point of view, it requires full-time employees to talk to the patients and the insurance company,” said Daniel Pambianco, president of the American College of Gastroenterology and a physician. “Then, it’s often just a denial.”

Appeals to the initial denial, or just wrangling a response from insurance companies, can further drag out the process. The paperwork itself is usually a nightmare, Pambianco said. Often, doctors trying to get procedures and medications approved wind up requesting a peer-to-peer call, allowing them to speak with a doctor who works for the insurance company and can assess the medical necessity of the request. But the doctors who work for insurers are rarely in the same specialty as the prescribing clinician. In the meantime, the patient is left waiting.

Soon, all that will await patients who may have gastrointestinal or colorectal cancer.

“They’re making decisions for patient care, but they don’t see the patient.”


“Let’s say you come in, and you have gastric pain, nausea, dark stool, we need to perform an endoscopic exam to see — do you have cancer? It’s a clear clinical picture, but now we have to get approval through that. The back and forth is very frustrating,” Pambianco said. “We are going through a process where we are dealing with a company practicing medicine without a license. They’re making decisions for patient care, but they don’t see the patient. They’re not a clinician dealing with the patient’s problem.”

With potentially weeks or months of back and forth trying to get a colonoscopy approved, gastroenterologists worry the new United policy will discourage patients, who must sometimes get involved to help push the process through, from completing the procedure. Some studies have shown that patients are less likely to fill prescriptions or treatments that need prior authorization.

Given that colonoscopies are inherently inconvenient and uncomfortable, requiring patients to essentially spend a day guzzling laxatives, physicians are especially worried about the impact of extra hurdles.

“Patients aren’t necessarily eager to have a colonoscopy,” said David Lieberman, a gastroenterologist at Oregon Health and Science University. “If you put a barrier in front of them to schedule that procedure, they may not end up completing.”

How United’s new policy will impact high-risk patients

There is one key procedure that United’s new policy does not apply to: screening colonoscopy. That means doctors will be able to continue performing routine cancer screenings for most people covered by United. But this detail still isn’t much solace to gastroenterologists.

That’s because surveillance and diagnostic colonoscopy, both of which are also supposed to detect colorectal cancer, will require prior authorization.

Whereas screening colonoscopies are for asymptomatic, apparently healthy people, diagnostic colonoscopy is for individuals with symptoms of cancer or other conditions, a positive stool test, or for people who have polyps detected on routine screening colonoscopies. Surveillance colonoscopy, meanwhile, is for individuals who have a personal history of cancer or colorectal polyps, or conditions that predispose them to colorectal cancer like Lynch syndrome — genetic repair mutations that increase the lifetime risk of colorectal cancer up to 80%.

All three of these procedures search for colorectal polyps, which can develop into cancer. Removing them during the colonoscopy can prevent colorectal cancer entirely.

United’s new policy means that people who are at the lowest risk of colorectal cancer should not have to deal with prior authorizations, UCLA’S May explained. But people at the highest risk will.

When UnitedHealthcare starts to require prior authorization for these procedures, Johnson worries for the patients covered by the insurer. High-risk patients cannot wait too long for colonoscopies. The alternative is to pay for the procedure themselves, but people cannot always afford to pay out-of-pocket to have them immediately.

Colonoscopies, alongside associated administrative fees, can cost thousands of dollars. In that sense, experts have cautioned, the prior authorization policy could worsen disparities for low-income individuals who cannot pay out-of-pocket or spend hours trying to overcome administrative barriers.

Johnson worries that will lead patients to think, “Last year, I had no polyps. This year I just don’t have the money to do it, so maybe I’ll skip,” Johnson said. “You know, futures are dictated by health care policy. When I heard this policy, I thought, how can this change be implemented without a conversation with the people it would affect the most — us patients?”

Are patients getting too many colonoscopies?

Gastroenterology professional societies, like the American Gastroenterological Association and the American College of Gastroenterology, immediately reached out to UnitedHealthcare after the new prior authorization policy announcement. They scheduled meetings with the insurer, hoping to learn as much as they could about the requirement and why United had created it. More than anything, they hoped to dissuade the company from implementing the policy.

They failed.

“We were having the if conversation. If this is worthwhile to do,” said Penn’s Mehta. “They were saying, ‘This is happening.’”

Mehta and other gastroenterologists present at the meeting said that the UnitedHealthcare representatives told them the policy was to reduce over-utilization of endoscopic procedures, including colonoscopy and upper endoscopy. United claimed that physicians were performing these procedures on patients who simply don’t need them, gastroenterologists told STAT in interviews.

Source link: https://www.statnews.com/

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