Doctors And Patients Are Worried This Large Health Insurer's New Policy Will Delay Care

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UnitedHealthcare's new policy will require doctors and patients to be cleared before routine procedures, including certain colonoscopies and throat, stomach and gastrointestinal brooms.

LaTesha Harrison needs one or two gastrointestinal exams every year so her doctor can track complications of her Crohn's disease.

But a woman from suburban Baltimore fears those necessary procedures will soon be delayed, even if it's swelling, pain, or an inability to eat. Beginning June 1, UnitedHealthcare will require doctors and patients to obtain authorization before routine procedures, including certain colonoscopies and throat, stomach, and gastrointestinal lavages.

“If I have to wait a week, two or three weeks, it could lead to hospitalizations and emergency care, which is expensive for me,” said Harrison, who works as a nurse at the Baltimore District Hospital. "I have a job. I am a mother." I can't take the (time) and go to the emergency room just to get an endoscopy so my doctor can decide if I need to take certain medications to help with an outbreak."

Digestion doctors are writing letters, lobbying executives and posting on social media to stop a new policy from UnitedHealthcare, one of the nation's largest insurance companies.

The controversy is the latest example of how doctors and healthcare organizations are battling insurance companies' efforts to implement "prior authorizations," which require the insurance company's approval before agreeing to pay for certain prescriptions, medical services, or treatments.

Health insurers say reforms are needed to cut down on unnecessary health care, reduce potential harm and stop consumers from paying for things they don't need.

But physician groups say the policy delays treatment, harms patients and creates unnecessary paperwork that results in higher administrative costs. They argue that patients can opt out of treatment or have to pay the bulk of their healthcare costs.

United Health. fixes needed

UnitedHealthcare's new policy for its 26.7 million privately insured members requires physicians to obtain authorization before performing endoscopic procedures used to diagnose diseases of the esophagus, stomach, or colon. Endoscopic procedures involve the insertion of a flexible tube with a light and a camera to allow visualization of the digestive tract.

Consumers will not need approval for a ten year colonoscopy, which is recommended for screening adults over 45 for colon cancer. Under the Affordable Care Act, insurers must cover preventive care that is classified as Class A or Class B by the US Preventive Services Task Force, an independent advisory group that evaluates medical research, treatments, and services. The Task Force rated screening colonoscopy as 'A' for adults aged 50–75 and 'B' for the 45–49 age group.

But patients like Harrison should be scheduled for another colonoscopy to diagnose symptoms or monitor changes.

In a statement to USA TODAY, UnitedHealthcare said that prior authorizations are required to ensure that shared domains are secure, available, and effective for customers.

According to UnitedHealthcare:

• The average out-of-pocket cost for people who have a follow-up colonoscopy, laryngoscopy, or gastroscopy is $944 for insurance plans.
• Some insurance company clients experience side effects or complications of endoscopic procedures. This complication results in approximately 2,500 hospital admissions and approximately 6,000 emergency room visits per month following these procedures, according to the insurance company.

“We require healthcare professionals to follow guidelines and evidence-based practices developed by their gastroenterology companies to help provide timely, safe, and clinically appropriate care to our members,” UnitedHealthcare said in an emailed statement. "Physicians who will be most affected by this new policy are those who no longer adhere to these evidence-based practices, who have been retrained by medical societies associated with gastroenterology."

Private insurance plans typically require consumers to pay a portion of their health care bill in accordance with cost-sharing requirements such as upfront payments or deductibles, which are the amount a person must pay before coverage begins. Many insurance plans also require consumers to pay premiums or a percentage of their medical bills until they reach their cash limit. Thus, the more doctors or surgical centers, the more consumers pay.

UnitedHealthcare cites medical research showing that excessive use of domains exposes patients to unnecessary risk and cost. A study published in the American Journal of Gastroenterology evaluated nearly 115,000 patients with and without Barrett's esophagus, a condition in which the lining of the esophagus is damaged by acid reflux and can progress to cancer. During the study, disease-free patients underwent repeat endoscopy, and some of them were re-examined shortly thereafter without precancerous cells.

A small 2022 study found that less than half of 532 follow-up colonoscopies met the 2020 recommendations of the U.S. Intercommunity Task Force on Colorectal Cancer, which includes three specialized groups that develop colon cancer screening guidelines. The study found that doctors have been particularly slow to adapt to the updated recommendations for low-risk cases.

David Allen, spokesman for American Health Insurance Plans, an industry group that represents private insurers, said prior authorizations are needed to ensure safe, effective and affordable treatment.

“Independent research shows, and clinicians agree, that differences in patient care can lead to inappropriate, unnecessary, and more expensive treatments that can harm patients,” Allen said. Prior authorization helps save patients and consumers money and ensures safe patient care.”

"I'm trying to save money... back pain"

Three specialized groups - the American College of Gastroenterology, the American Gastroenterological Association and the American Society of Gastrointestinal Endoscopy - as well as dozens of groups of doctors, hospitals and patients sent letters urging the insurance company to revise the policy.

In a letter endorsed by 170 physicians, medical societies, patient groups and hospitals, the organization said the policy was "erroneous and misguided" and would prevent or delay the diagnosis of colon cancer, the deadliest form of cancer among men. 50 and up to three. More dangerous for women under 50.

While screening colonoscopies are allowed, doctors warn patients to repeat colonoscopies if polyps are found, cancerous tissue is removed, or symptoms develop.

While other insurance companies have pre-clearance for endoscopy, the three panels said, "UnitedHealthcare's broad, exceptional approach to stroke will disproportionately impact our profession and our patients."

UHC patients will inevitably be disappointed because most colonoscopies are follow-up or diagnostic; Phoenix-based gastroenterologist Dr. Paul Berggren said two categories will now require prior authorization.

When doctors remove polyps after a colonoscopy, Berggren says, they ask the patient to come back in three to five years. But he fears that some patients will skip or delay these recommended procedures, or that insurance companies will deny permission.

"They're trying to save money for UnitedHealthcare, and they're doing it by having patients get advice from their doctors who follow accepted guidelines," Berggren said.

Louisville gastroenterologist Dr. Paul Brown said the policy would delay or skip diagnosis of stomach, throat and colon cancers. He fears that if doctors delay treatment planning in an attempt to get insurance company approval, patients will be given a false sense of security.

“Sometimes they misinterpret it because we think it’s OK to be late and therefore they may be more late or forget,” Brown said. "So it becomes a missed diagnosis, which is a bigger problem."

1 in 3 groups of physicians employ staff to process prior clearances

The fight for pre-authorization by health insurance companies extends far beyond gastrointestinal and colon cancers.

According to an American Medical Association survey of physicians, a typical medical practice allows for 45 prior approvals per physician per week. According to the AMA, this means 14 hours of administrative work per week. More than 1 in 3 doctor's offices only hire staff with prior approval.

Last year, the Office of the Inspector General of the US Department of Health and Human Services found that 13 percent of pre-authorization applications denied by private Medicare Advantage plans will be approved under traditional government-managed Medicare standards. These private Medicare plans also rejected 18% of claims that met Medicare coverage guidelines.

Amid complaints from doctors and patients about prior authorizations, the Centers for Medicare and Medicaid Services proposed new prior authorization standards for private Medicare and Medicaid plans starting in January 2026.

According to an analysis by KFF, a non-profit health policy foundation, the proposed rule would require insurers to do the following with respect to prior authorizations:

• Use a standard computer interface to apply.
• Reducing the processing time of applications.
• Publish statistics annually.

Kai Bestina, vice president and co-director of the KFF program, said that while the proposed rule would place more emphasis on pre-approvals for publicly funded health insurance plans and add some requirements to ACA market plans, it leaves insurance plans with less oversight. . owner Protect patient and consumer.

For private health insurance plans, "there are no rules about when you can use prior authorization," Bastina said. "For the most part, plans make those decisions, and they don't need to be told why."

Ken Oltaker is on Twitter at @kalltucker or can be emailed to alltuck@usatoday.com.

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