UnitedHealthcare (UHC) recently announced it would be pausing a controversial policy requiring prior authorization for certain gastroenterology endoscopy services for commercial plan members that was set to take effect June 1, 2023. The move comes amid sharp pushback from many in the healthcare community. In place of the prior authorization policy, UHC will instead implement an optional advance notification process where physicians voluntarily submit patient data for clinical review, prior to performing certain gastroenterology endoscopy services. 

In order to be eligible for the payor’s Gold Card program, scheduled to launch in 2024, physicians must submit advance notifications, according to UHC’s FAQ.

The California Medical Association (CMA) had submitted a letter in opposition to the UHC prior authorization policy, concerned that it was an unnecessary, administrative burden that would simply delay patient access to medically necessary diagnostic services. 

The letter states that the administrative burden of providing the documentation for a prior notification is essentially the same as that associated with a prior authorization, without a guarantee of payment as required under California law.

According to the FAQs page, UHC will use the data received through advance notification to accelerate gold carding for eligible physician groups in early 2024. During this period, the payor will not issue medical necessity denials for procedures that are not aligned with clinical evidence or issue administrative denials for failure to submit advance notification. 

UHC said it has not yet determined whether it will pursue additional notification or potential prior authorization requirements for these services for physicians who do not qualify for the Gold Card program. Previous estimates from UHC were that only 10% of providers are expected to qualify for a Gold Card.

CMA also remains opposed to the implementation of the prior authorization policy for the estimated 90% of physicians who are not expected to qualify under the payor’s prior authorization Gold Card program. CMA believes that targeted provider education will prove to be more effective and less costly for all in the long term if UnitedHealthcare’s goal is to control costs and over-utilization.