LaTesha Harrison needs one or two scopes of her digestive system every year so her doctor can track her complications from Crohn’s disease.
But the suburban Baltimore woman worries these necessary procedures will soon be delayed, even when she feels bloated, aches or can’t eat. Beginning June 1, her health insurer, UnitedHealthcare, will require doctors and patients to get authorization before common procedures including some colonoscopies and scopes of the throat, stomach and digestive tract.
“If I have to wait one, two or three weeks, that can land me in the hospital and the emergency room and that’s costly to me,” said Harrison, who works as a nurse at Baltimore-area hospital. “I have a job. I’m a mother. I can’t take (time) off and go to the emergency room just to get a scope so my doctor can see if I need to be on a certain type of medication to help me through my flare.”
Doctors specializing in digestive issues are writing letters, pressuring executives and posting on social media in a campaign to halt the new policy being implemented by UnitedHealthcare, one of the nation’s largest health insurers.
The controversy is the latest example of how doctors and medical organizations are fighting insurers’ efforts to implement “prior authorizations,” which require an insurer’s consent before they agree to pay for certain prescriptions, medical services or treatments.
Health insurers say these reviews are needed to limit unnecessary medical services, reduce potential harms and make sure consumers don’t pay for care they don’t need.
But doctor groups say these policies delay care, harm patients and create unnecessary paperwork that contribute to higher administrative costs. Patients might choose to skip care or be forced to pick up a larger share of their health spending, they argue.
UnitedHealthcare: Reviews needed
UnitedHealthcare’s new policy for 26.7 million members with private insurance coverage will require doctors get authorization before doing endoscopy procedures used to diagnose diseases in the esophagus, stomach or colon. Endoscopy procedures involve inserting a flexible tube with a light and camera that allows them to see the digestive system.
Consumers won’t need authorization to get once-a-decade screening colonoscopies recommended for adults over 45 to check to colon cancer. Under the Affordable Care Act, insurers must cover preventive care assigned and “A” or “B” grade by the U.S. Preventive Services Task Force, an independent advisory panel that evaluates medical tests, treatments and services. The task force assigned an “A” grade to screening colonoscopies for adults ages 50 to 75 and a “B” grade for ages 45 to 49.
But other colonoscopies to diagnose symptoms or monitor for changes in patients such as Harrison will need to be approved.
In a statement provided to USA TODAY, UnitedHealthcare said prior authorizations are needed to make sure common scopes are safe, affordable and effective for their customers.
According to UnitedHealthcare:
- The average out-of-pocket cost for surveillance colonoscopies or scopes of the throat or stomach is $944 for their private insurance plans.
- Some of the insurer’s customers experience side effects or complications from endoscopy procedures. Every year, these complications result in nearly 2,500 hospital stays and nearly 6,000 emergency room visits within a month of these procedures, according the insurer.
“We are asking health care professionals to follow the guidelines and evidence-based practices developed by their own gastroenterology medical societies to help ensure our members have timely access to safe and clinically appropriate care,” UnitedHealthcare said in an emailed statement. “The physicians who will be most affected by this new policy are those who are not already following these evidence-based practices, which again, were developed by gastroenterology-related medical societies.”
Private insurance plans typically require consumers to pay a portion of a medical bill, through cost-sharing requirements such as copayments or deductibles, which is the amount someone must pay before coverage kicks in. Many insurance plans also require consumers to pay coinsurance, or a percentage of their medical bill, until they reach out-of-pocket limits. So the more a doctor or surgery center charges, the more consumers typically pay.
UnitedHealthcare cited medical studies that reported overuse of scopes have exposed patients to unnecessary risks and costs. One study in the American Journal of Gastroenterology assessed nearly 115,000 patients with or without Barrett’s esophagus, a condition in which the lining of the esophagus is damaged by acid reflux and can turn cancerous. The study found patients without the condition received surveillance endoscopies, and some with without precancerous cells were re-examined too soon, the study reported.
A small 2022 study found slightly less than half of 532 surveillance colonoscopies complied with 2020 guideline from the U.S. Multi-Society Task Force on Colorectal Cancer, which includes three specialist groups that developed colon cancer screening recommendations. Doctors were particularly slow to adapt to updated recommendations for low-risk cases, the study found.
David Allen, a spokesman for America’s Health Insurance Plans, an industry group representing private insurers, said prior authorizations are necessary to ensure safe, effective and affordable care.
“Independent studies show, and doctors agree, that differences in how care is provided to patients can lead to inappropriate, unnecessary and more costly medical treatments that can harm patients,” Allen said. “Prior authorization helps save money for patients and consumers and protects the safe care of patients.”
‘Trying to save money … on the backs of patients’
Three specialist groups − American College of Gastroenterology, American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy − and dozens of doctors, hospitals and patient groups have sent letters urging the insurer to reconsider the policy.
In one letter endorsed by an alliance of 170 doctors, medical societies, patient groups and hospitals, the organization said the policy is “flawed and misguided” and will prevent or delay the diagnosis of colon cancer, the deadliest cancer among men under 50 and third deadliest for women under 50.
Although screening colonoscopies are allowed, doctors warn of a chilling effect for patients who need follow-up colonoscopies if polyps are found, cancerous tissue removed or concerning symptoms surface.
While other insurers have prior authorization on endoscopies, the three specialist groups argue UnitedHealthcare’s “broad-stroke exclusionary approach will disproportionally impact our specialty and patients.”
Dr. Paul Berggreen, a Phoenix gastroenterologist, said UnitedHealthcare-insured patients will inevitably be frustrated because most colonoscopies are surveillance or diagnostic − two categories that will now require prior authorization.
When doctors remove polyps following a screening colonoscopy, Berggreen said they typically ask the patient to return in three to five years. But he fears some patients will skip or delay such recommended procedures, or the insurer will deny authorization.
“They’re trying to save money for UnitedHealthcare, and they’re doing it on the backs of patients who are getting advice from their physicians who are following accepted guidelines,” Berggreen said.
Dr. Paul Brown, a Louisville gastroenterologist, said the policy will result in delayed diagnosis or missed cancers of the stomach, throat and colon. He worries patients will get a false sense of security if doctors delay scheduling care while seeking the insurer’s approval.
“They sometimes misinterpret that as we think it’s OK to delay and then they may delay it further or forget about,” Brown said. “Then that becomes a missed diagnosis, which is even a greater problem.”
1 in 3 doctor groups hire staff to process prior authorizations
The battle over health insurance companies implementing prior authorizations extends beyond digestive and colon cancers.
The typical medical practice completes 45 prior authorizations for each doctor per week, according to an American Medical Association survey of physicians. That translates to 14 hours of administrative work per week, according to the AMA. More than 1 in 3 medical practices hire staff to work exclusively on prior authorizations.
Last year, the U.S. Department of Health and Human Services Office of Inspector General found 13% of prior authorization requests rejected by private Medicare Advantage plans would have been allowed under traditional, government-run Medicare’s criteria. These private Medicare plans also denied 18% of claims that met Medicare’s coverage rules.
Amid doctor and patient complaints about prior authorizations, the Centers for Medicare and Medicaid Services has proposed new prior authorization standards beginning January 2026 for private Medicare and Medicaid plans.
According to an analysis by the health policy nonprofit KFF, the proposed rule would require insurers to do the following on prior authorizations:
- Use a standard computerized interface for submitting a request
- Shorten the time frame for deciding a request
- Publicly report statistics each year
While the proposed rule could bring more scrutiny to prior authorizations on publicly-funded health insurance plans and add some requirements to Affordable Care Act marketplace plans, there’s less oversight on private insurance plans, said Kaye Pestaina, a vice president and co-director of KFF’s program on patient and consumer protections.
For private health insurance plans, “there’s no regulation of when you can use prior authorization,” Pestaina said. “For the most part, plans make those decisions and they don’t have to show why.”
Ken Alltucker is on Twitter at @kalltucker, or can be emailed at alltuck@usatoday.com
