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STAT: ‘Stunning’ Change to United’s Colonoscopy Coverage Roils Physicians and Patients

From STAT: 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. 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. Read more at STAT.