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Doctors And Patients Are Worried This Large Health Insurer's New Policy Will Delay Care
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."
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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 neededUnitedHealthcare'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 for 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:
"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 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 authorizationsThe 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:
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
This article originally appeared on USA TODAY: Doctors and patients are worried this large health insurer's new policy will delay care
Health Plans Could Soon Reduce Coverage For Preventive Care. Here's What To Know
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Tens of millions of Americans could be affectedThe ACA's preventive services mandate covered most people who have private health insurance, either through their employer or from the public exchange, Donovan said.
Around 100 million people with private insurance got preventive care required under the ACA in 2018, one estimate found, making it the provision with the widest reach. Insurers generally must not impose copays or deductibles on the recommended preventive care.
The ruling doesn't appear to have a direct impact on those covered by Medicaid or Medicare, experts say.
Cancer screenings, heart meds among care at riskThe decision out of Texas means insurers are no longer required to provide free coverage based on recommendations made from the U.S. Preventive Services Task Force since 2010.
However, the other two panels that advise the government on preventive care, the Advisory Committee on Immunization Practices and the Health Resources & Services Administration, may have made similar recommendations that will prevent some kinds of care from losing coverage, Donovan said.
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Still, because of the ruling, people in their late 40s may face higher costs for colorectal screenings.
Similarly, certain lung cancer screenings for adults between the ages of 50 and 80 with a history of smoking could be subject to new out-of-pocket costs, according to the Kaiser Family Foundation.
In addition, some medications to prevent heart disease, such as statins, and drugs to lower the risk of breast cancer may also be subject to copays, deductibles and coinsurance now.
Advocates are also concerned that costs will rise for PrEP, a medication highly effective for preventing H.I.V.
Changes unlikely to be immediateAlthough the decision is likely to drive up health-care costs for some people, Kosali Simon, professor of health economics at the O'Neill School at Indiana University, said there was little reason for panic just yet.
"Many preventive care services are not covered by this decision," Simon said.
Insurers are also not likely to make changes to their coverage in the middle of the plan year, she added. That means any reduced coverage might not kick in until 2024. It's also possible insurers will wait until the legal disputes over the provision are resolved before amending their policies.
Health plans will still be required to ensure no copays for many preventive services, including birth control and mammograms, Simon said. Some states have their own mandates, meanwhile, on free preventive care.
Patients can check in with insurersThose who are worried about changes to their health-care coverage should call their insurer and ask about any upcoming scheduled appointments, Donovan said.
Whatever you learn, Donovan said, "We recommend going forward with any planned appointments. These preventive services may save your life."
Appeals Court Pauses Ruling That Threatened Free Preventive Health Care
The NewsA federal appeals court on Monday temporarily blocked a lower court decision that overturned the Affordable Care Act's requirement that all health plans fully cover certain preventive health services.
The move by the U.S. Court of Appeals for the Fifth Circuit in New Orleans will put on hold a decision from March that had threatened insurance coverage for recommended services like depression screenings for teenagers and drugs that prevent transmission of H.I.V. The Justice Department had appealed the decision, and the appeals court's stay will stand while the appeals process plays out.
Why It Matters: Preventive health services are popular.The ruling earlier this spring overturned one of the most popular requirements of the Affordable Care Act by taking away the financial barriers to a range of preventive services. It had taken effect immediately nationwide and had the potential to affect roughly 150 million Americans enrolled in private health insurance, either through employer-sponsored plans or through the Obamacare marketplaces.
While the case is under review, full coverage for preventive services will be legally required.
Background: The Affordable Care Act under fire — again.Earlier this year, Judge Reed O'Connor of the Federal District Court for the Northern District of Texas ruled that insurers did not have to cover any of the services that had been recommended by the United States Preventive Services Task Force since 2010. His reasoning: The task force is not appointed by Congress and therefore did not have the constitutional authority to decide what services a health insurer must cover.
That ruling had built upon previous ones: In 2018, Judge O'Connor had ruled that the A.C.A. Was unconstitutional (though the Supreme Court later overturned that decision). Last September, he ruled that the A.C.A.'s mandate that employers cover a daily H.I.V. Prevention pill called PrEP violated a company's religious freedoms.
What's Next: A march toward the Supreme Court.For now, employers will still be required to provide no-cost coverage for preventive services. But the Fifth Circuit is conservative-leaning, and the case could eventually end up at the Supreme Court as yet another challenge to the Obamacare health law.
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