Sir Andrew Witty
Chief Executive Officer
UnitedHealth Group
9900 Bren Rd E
Minnetonka, MN 55343
[email protected]
May 8, 2023
Dear Sir Andrew,
The undersigned organizations urge you not to implement United Healthcare’s (UHC) gastrointestinal (GI) endoscopy prior authorization program. It is flawed and misguided and will harm patients, limit access to care for vulnerable populations, delay diagnosis of colorectal cancer in younger populations, and needlessly increase physician and practice burden. Nearly 1,500 patients and their physicians have sent letters to UHC expressing the harms, both immediate and long term, that the program will cause.
Impact to patients
The National Cancer Institute confirms that “Colorectal cancer is a leading cause of cancer death among people under 50 in the United States, with rates of new diagnoses still climbing in this age group.”i However, UHC’s prior authorization program for GI endoscopy, even though it purportedly excludes screening colonoscopy, will most certainly have a chilling effect on patients’ willingness to undergo medically recommended subsequent colonoscopy examinations after polyps or cancers are removed or for diagnostic testing when they have red flag symptoms. Eighty percent of physicians report that the prior authorization process can lead to treatment abandonment.ii This policy will also likely exacerbate existing sociodemographic disparities in care and outcomes, as our most vulnerable patients are most subject to access issues.
UHC’s program will undoubtedly cause delays in care for high-risk individuals. The Center for Consumer Information and Insurance Oversight (CCIIO) states that “Identification of ‘high-risk’ individuals is determined by clinical expertise.iii If a medical provider determines that a patient is high-risk for colorectal cancer, and a U.S. Preventive Services Task Force recommendation applies to that high-risk population, that service is required to be covered in accordance with the requirements of the interim final regulations, without cost-sharing.” However, UHC will require those patients to wait to receive approval via its prior authorization process before they can receive treatment even though they have been deemed at ‘high risk’ for colorectal cancer by a physician.
UHC will require prior authorization for most GI endoscopic procedures, many of which are low volume procedures and are performed for patients who are bleeding, not able to swallow, vomiting, or having pain. For example, esophagoscopy (CPT 43200) and esophagoscopy with flexible guidewire dilation (CPT 43226), which are most commonly performed by otolaryngologist-head and neck surgeons, are extremely low volume procedures required to treat very sick patients, many of whom are at risk for esophageal candidiasis and reflux esophagitis with stricture. Despite the low volume and urgent need to treat this patient population both procedures will require prior authorization under UHC’s new program. For those patients whose treatment requires prior authorization, 94% of physicians report delays in access to medically necessary care.iv
With the increase in early colorectal cancer diagnoses, continued health disparities, and delayed care caused by the COVID-19 pandemic, our most vulnerable patients will be hurt by this program. Many patients who are hesitant to undergo an endoscopy may interpret delays caused by your prior authorization program as an indication that UHC does not believe the care recommended by their physician is medically appropriate. We urge you to consider the unintended consequences that limiting access to services on the colorectal cancer screening continuum (e.g., diagnostics and surveillance colonoscopy) will have on vulnerable populations.
Although unintended, screening colonoscopy will, in fact, require prior authorization
Although UHC says that screening colonoscopy will be excluded, UHC has not provided instruction on how to code screening colonoscopy or one that results in a therapeutic intervention. If UHC truly intended to exclude screening colonoscopy, explicit coding instructions should have been provided the day the program was announced. Unless instructions are provided and time for physician education is allowed, prior authorization will be needed for screening colonoscopies.
Increasing physician burden
In addition to harming patients, the GI endoscopy prior authorization program will cause undue burden to practices at a time when UHC says it is attempting to ease physician burden. Because endoscopists often do not know exactly what procedure(s) they will be providing during an endoscopy, UHC clinician representatives have told us that endoscopists will need to request prior authorization for the base code (e.g., 43235 for EGD and 45378 for colonoscopy). Therefore, from a practice operations standpoint, every upper and lower endoscopic and capsule endoscopy procedure will inadvertently require prior authorization, not just the 61 codes listed in UHC’s GI Endoscopy Procedures list.
According to studies by the American Medical Association, the average practice completes 45 prior authorizations per week per physician, resulting in 14 hours of paperwork per week. Over a third of physicians have staff that work exclusively on prior authorization alone.v Physicians and staff are already overburdened with insurance program requirements. Implementing yet another program that adds to the already high administrative burden physicians face for procedures that are medically appropriate and indicated, and potentially lifesaving, seems like a waste of UHC’s resources and, most certainly, physicians’ time.
No evidence of overutilization data provided
Many of the CPT codes covered by the GI endoscopy prior authorization program are low volume and could not be considered overutilized. On several occasions, we asked UHC to share de-identified, aggregate data from UHC showing recent evidence of overutilization. Our request was denied. We asked UHC to identify the procedures of concern and offered to partner together to educate physicians on appropriate utilization in adherence to published guidelines. UHC declined to identify specific procedures of concern and instead referred to studies they claim suggest overutilization in GI endoscopy. To date, we have received no information from UHC that substantiates overutilization for any GI endoscopic or capsule endoscopy procedure.
Controlling costs at the expense of patient care
If, as UHC purports, the GI endoscopy prior authorization program was designed to ensure appropriate care based on guidelines, it should not include the low volume esophagoscopy and colonoscopy through stoma procedures. This program has clearly been designed to control costs by broadly limiting care rather than improving patient care.
UHC’s short-sighted GI endoscopy prior authorization program has not been well designed, will result in delays for medically necessary care for patients, adds unnecessary paperwork burden to physicians and their staff, and may violate CCIIO recommendations. For these reasons, we urge you not to implement the GI endoscopy prior authorization program.
Sincerely,
Akron Digestive Disease Consultants, Inc.
Alabama Gastroenterological Society
Alaska State Medical Association
Ambulatory Surgery Center Association
American Academy of Otolaryngology-Head and Neck Surgery
American Association of Neurological Surgeons
American College of Gastroenterology
American College of Obstetricians and Gynecologists
American College of Physicians
American College of Surgeons
American Gastroenterological Association
American Osteopathic Association
American Society for Gastrointestinal Endoscopy
American Society of Cataract and Refractive Surgery
American Society of Echocardiography
American Urological Association
Arizona Digestive Health
Arizona Gastrointestinal Associates
Arizona Medical Association
Arkansas Gastroenterology
Arkansas Medical Society
Association for Clinical Oncology
Austin Gastroenterology, P.A.
Borland Groover
Boulder Medical Center
California Medical Association
Capital Digestive Care
Carolina Digestive Diseases PA
Cedar Valley Medical Specialists
Cedars-Sinai Medical Center
Central Arizona Medical Associates
Centura Hospital
Charleston Area Medical Center, Charleston, WV
Cleveland Clinic Foundation
Color of Crohn’s & Chronic Illness
Colorectal Surgical & Gastroenterology Associates, PSC
Community Healthcare Network
Community Liver Alliance
Cone Health Annie Penn Hospital
Congress of Neurological Surgeons
Connecticut GI
Crazy Creole Mommy Life
Crohn’s & Colitis Foundation
Crohn’s and Colitis Young Adults Network
Crozer Health Gastroenterology
Dartmouth-Hitchcock Medical Center
David Geffen School of Medicine at UCLA
Diamond Gastroenterology
Digestive and Liver center of Florida
Digestive Care Consultants LLC
Digestive Disease Care PC
Digestive Disease Consultants Of Orange County
Digestive Disease Consultants Orlando
Digestive Disease National Coalition (DDNC)
Digestive Diseases Associates
Digestive Health Associates of Texas
Digestive Health Physicians Association
Digestive Health Specialists
Digestive Healthcare Clinic
Digestive Medical Services Inc.
Dignity Health
East Bay Center for Digestive Health
Eisenhower Medical Center
Emory University
Endoscopy Center of Bainbridge
Endoscopy Center of West Central Ohio, LLC
Fight Colorectal Cancer
Florida Gastroenterologic Society
Florida Medical Association
Forest hills gastroenterology
Gastro Health
Gastro Office
Gastro One
Gastroenterology Associates (Kingsport, Bristol, Abingdon, TN)
Gastroenterology Associates, Inc, 44 West River Street, Providence, RI 02904
Gastroenterology Associates, PC (Gainesville, VA)
Gastroenterology Diagnostic Center
Gastroenterology Group, AMC
Gastroenterology Specialists, Inc.
Gastrointestinal Specialists of Long Island
Geneoscopy, Inc.
GI Alliance
GI Associates LLC, Milwaukee, WI
GI Specialists of Georgia, PC
Girls With Guts
Greater Baltimore, Medical Center
Hca palm beach gastroenterology
Hershey Endoscopy Center
Hudson Valley Gastroenterology
IBDMoms
Idaho Medical Association
Indiana University
Integrated GI Consultants
International Foundation for Gastrointestinal Disorders
Johns Hopkins University School of Medicine
Kentucky Medical Association
Lee Memorial Hospital System (LMHS)
Loma Linda University School of Medicine
Maine GI Society
Massachusetts Medical Society
Mayo Clinic – Division of Gastroenterology & Hepatology, Scottsdale, AZ
Mayo Clinic Health System
MedChi, The Maryland State Medical Society
Medical Association of Georgia
Medical Group Management Association
Medical Society of DC
Medical Society of the State of New York (MSSNY)
Medtronic Gastrointestinal
Memorial Sloan Kettering Cancer Center
Mercy Medical Group, Dignity Health Medical Foundation
Metro Atlanta Gastroenterology LLC
Michigan GI Society
Midwest Gastrointestinal Associates
Mississippi State Medical Association
Missouri Gastroenterology Society (MOGI)
Missouri State Medical Association
MultiCare Digestive Health
Nebraska Medical Association
New Mexico Medical Society
North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
North Carolina Medical Society
North Dakota Medical Association
Northeastern Gastroenterology Associates PC
Ohio Gastroenterology Group, Inc
Ohio Gastroenterology Society
Olympus Corporation of the Americas
One GI
Optum/tri
Oregon Digestive
PACT Gastroenterology Center
Pennsylvania Medical Society
Pennsylvania Society of Gastroenterology (PSG)
Piedmont Digestive Diseases Associates
Pinehurst Medical Clinic Gastroenterology
Premier Gastroenterology, Fayetteville, NC
Premiere Gastroenterology at Quiet Cove
Rhode Island Medical Society
Rio Grande Gastroenterology Consultants
Saratoga Schenectady Gastroenterology Associates
SGRDH-Institute of Liver Gastroenterology & Pancreatico-Biliary Sciences
Shenandoah Valley Gastroenterology Center, PLLC
Sinai Hospital, Baltimore, MD
South Asian IBD Alliance (SAIA)
South Carolina Gastroenterology Association
South Carolina Gastroenterology Association Foundation
SSM Health Digestive Institute
Texas Digestive Disease Consultants
Texas Medical Association
Texas Society for Gastroenterology and Endoscopy
The Association of Black Gastroenterologists and Hepatologists (ABGH)
The Ohio State University
The Oregon Clinic Gastroenterology
United Ostomy Associations of America
Univeristy of Louisville Physicians
University Hospitals Cleveland Medical Center
University of Chicago Digestive Diseases Center
University of Michigan Health
University of Nebraska Medical Center
University of North Carolina
University of Pennsylvania – Penn medicine
University of Texas in San Antonio
University of Virginia Health System
University Suburban Endoscopy Center
US Digestive Health
UT Houston
Valley GI Consultants
Vanguard Gastroenterology
Vermont Gastroenterology
Virginia Mason Franciscan Health
West Virginia University Medicine
Woodholme gastroenterology
Wyoming Medical Society and the Wyoming Academy of Family Physicians
cc: Laurie Gianturco, MD, National Medical Director, Radiology, United Healthcare
Anne Docimo, MD, Chief Medical Officer, United Healthcare
Philip Kaufman, Chief Growth Officer, United Healthcare
i. https://www.cancer.gov/news-events/cancer-currents-blog/2020/colorectal-cancer-rising-younger-adults
ii. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
iii. https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs12
iv. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
v. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
