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 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:
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.
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“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 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
This article originally appeared on USA TODAY: United Healthcare to require pre-authorization for some colonoscopies
FAQs
What is gold carding in healthcare? ›
3 Several states are considering “gold carding” laws that would require health plans to waive prior authorization on services and prescription drugs ordered by providers with a proven track record of prior authorization approvals.
Can you bill for prior authorization? ›Can doctors charge for prior authorizations? Physicians and other healthcare providers do not usually charge for prior authorizations.
What is the purpose of a prior authorization? ›Prior authorization—sometimes called precertification or prior approval—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.
What is the meaning of prior authorization? ›Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.
What is the gold Card Act? ›This legislation would exempt providers, who received approval for 90% of their requests in the last 12 months, from prior authorization delays for Medicare Advantage beneficiaries. Additionally, the GOLD Card Act would allow physicians to appeal an attempt by a Medicare Advantage plan to rescind the exemption.
What is the gold standard in healthcare? ›In medicine
"Gold standard" can refer to the criteria by which scientific evidence is evaluated. For example, in resuscitation research, the "gold standard" test of a medication or procedure is whether or not it leads to an increase in the number of neurologically intact survivors that walk out of the hospital.
If you don't use a health care provider in your plan's network, then you are responsible for obtaining the prior authorization. If you don't obtain it, the treatment or medication might not be covered, or you may need to pay more out of pocket.
How much money does prior authorization save? ›According to the 2021 CAQH, providers could save 16 minutes per authorization if automated. That's a savings of almost 11 hours a week. By automating prior authorization transactions, providers and health plans could save $437 million each year.
Which is the most restrictive type of healthcare plan? ›An HMO is perhaps the most restrictive health plan type but may yield the lowest costs. In an HMO plan, members must generally receive healthcare services from doctors and hospitals in the plan's network.
What does PA mean on a prescription? ›The prior authorization (PA) process can be frustrating. Sometimes you may not find out that your medication requires PA until you hear from your doctor or the pharmacy that your prescription can't be filled.
Why would insurance deny a prior authorization? ›
Insurance companies can deny a request for prior authorization for reasons such as: The doctor or pharmacist didn't complete the necessary steps. Filling the wrong paperwork or missing information such as service code or date of birth.
Who grants preauthorization for treatments? ›When your doctor decides that you need a service or medication, and it requires pre-authorization from your health plan, your doctor's office will put a request into your health plan to get approval to perform the service or for the pharmacy to fill the prescription.
How does prior authorization affect patients? ›Prior authorization (also called “preauthorization” and “precertification”) refers to a requirement by health plans for patients to obtain approval of a health care service or medication before the care is provided. This allows the plan to evaluate whether care is medically necessary and otherwise covered.
How can I speed up my prior authorization? ›- Create A Follow Up Plan With Your Staff. ...
- Be Methodical About Working Authorizations. ...
- Ask For An Estimated Turnaround Time For The Completion Of An Authorization.
- Planned admission to a hospital or skilled nursing facilities.
- Surgeries.
- Advanced imaging, such as MRIs and CT scans.
- Transplant and donor services.
- Non-emergency air ambulance transport.
- Medical equipment.
- Specialty drug treatments.
The Black Card, is a rewards credit card that is the middle-tier offering from Luxury Card. The Gold Card is considered the higher end of the three cards. Benefits for each card vary and can include a 24/7 concierge service, gifts, and worldwide acceptance.
What is a copper gold card? ›What is the Coppers Gold Card? Coppers Gold Card grants you FREE entry for you and a friend. Also, with Coppers Gold Card you can say goodbye to those long queues. What do I have to do?
What does the Card Act do? ›Many credit cards have different annual percentage rates (APRs) for purchase, balance transfers and cash advances. The CARD Act limits how much interest you'll pay by requiring card issuers to apply any payment amounts over your minimum payment due to the balance with the highest interest rate.
When did the US go away from the gold standard? ›The U.S. abandoned the gold standard in 1971 to curb inflation and prevent foreign nations from overburdening the system by redeeming their dollars for gold.
Who does the gold standard benefit Why? ›A gold standard would reduce the risk of economic crises and recessions, while increasing income levels and decreasing unemployment rates. A gold standard puts limits on government power by restricting the ability to print money at will and increase the national debt.
Who does the gold standard benefit? ›
The advantages of the gold standard are that (1) it limits the power of governments or banks to cause price inflation by excessive issue of paper currency, although there is evidence that even before World War I monetary authorities did not contract the supply of money when the country incurred a gold outflow, and (2) ...
What are three drugs that require prior authorization? ›| Drug Class | Drugs in Class |
|---|---|
| Androgens-Anabolic Steroids | Androl-50, Danazol, Nandrolone, Oxandrin |
| Anticoagulants | Eliquis, Pradaxa, Xarelto |
| Antipsoriatic Agents | Otezla, Stelara, Taltz, Tremfya |
| Apokyn, Kynmobi | Apokyn, Kynmobi |
While you have an obligation to file claims in a timely manner, you cannot do so without the patient providing correct information. If the claim is denied because the patient did not provide accurate information, but you acted in good faith, you should balance bill the patient.
What are three possible reasons for preauthorization review denial? ›- 1) The services are not medically appropriate (47 percent).
- 2) The health plan lacks information to approve coverage of the service (23 percent).
- 3) The service is a non-covered benefit (17 percent).
Firms Denied Between 3% and 12% of Prior Authorization Requests.
Do you get pre authorization charges back? ›When using pre authorizations, there is no payment to refund, the hold is simply canceled. Overall, the process of accepting pre authorized charges is easy, and provides merchants with a slough of benefits, including reducing costs and gaining happy customers.
How long does prior approval take? ›This is known as 'prior approval' and it's likely you'll need to submit an application early on to see whether or not your project warrants this type of planning. Time required: on average, 8 weeks.
What is a disadvantage of a PPO plan? ›Disadvantages of PPO plans
Typically higher monthly premiums and out-of-pocket costs than for HMO plans. More responsibility for managing and coordinating your own care without a primary care doctor.
Disadvantages of HMOs
Medical professionals must be part of the plan's network. You can't visit a specialist without a referral from your family doctor. Emergencies must meet certain conditions before the plan pays.
Typically, managed care networks limit the ways patients can navigate them, and leverage payment structures like deductibles, copays, and monthly premiums to keep costs down.
Why is my insurance delaying my prescription? ›
Situations that may create a delay include: an incomplete or illegible prescription, manufacturer back orders, and medications that require prior authorization. However, we will notify you if there will be a delay with your prescription shipment.
Is a PA right under a doctor? ›An MD can work independently, while a PA must always work under the supervision of a doctor. PAs can't perform surgeries, but they can assist an MD during the procedure.
Can a pharmacist refuse to fill a prescription in Pennsylvania? ›(c) A pharmacist may decline to fill or refill a prescription if the pharmacist knows or has reason to know that it is false, fraudulent or unlawful, or that it is tendered by a patient served by a public or private third-party payor who will not reimburse the pharmacist for that prescription.
Why do health insurance companies deny their patients? ›There are a wide range of reasons for claim denials and prior authorization denials. Some are due to errors, some are due to coverage issues, and some are due to a failure to follow the steps required by the health plan, such as prior authorization or step therapy.
Why do insurance companies deny everything? ›Insurance claims are often denied if there is a dispute as to fault or liability. Companies will only agree to pay you if there's clear evidence to show that their policyholder is to blame for your injuries. If there is any indication that their policyholder isn't responsible the insurer will deny your claim.
Why would a PA be denied? ›Insurance companies can deny a request for prior authorization for reasons such as: The doctor or pharmacist didn't complete the steps necessary. Filling in the wrong paperwork or missing information such as service code or date of birth.
When a patient signs an Assignment of Benefits form who is the patient authorizing to receive the Benefits? ›By signing an Assignment of Benefits (AOB), a patient is authorizing the Insurance Carrier or Third-Party Administrator to make health insurance payments directly to the treating medical provider.
What is a physician who has agreed to accept a managed care plan's payments for services to subscribers called? ›IN-NETWORK PROVIDER: A provider who has contracted with a managed care plan and agrees to deliver medical services to enrollees for an agreed upon fee. INPATIENT: Refers to the status of a member who is in a 24-hour per day care facility and who receives diagnostic and/or treatment services.
What is difference between precertification and preauthorization? ›Prior authorization, also known as preauthorization, prior approval, or precertification, is a process that insurance companies use to determine whether a patient is eligible to receive certain procedures, medications, or tests, except in an emergency.
What triggers a prior authorization? ›The prior authorization process begins when a service prescribed by a patient's physician is not covered by their health insurance plan. Communication between the physician's office and the insurance company is necessary to handle the prior authorization.
How do you fight prior authorization denial? ›
You or your doctor contact your insurance company and request that they reconsider the denial. Your doctor may also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review” in order to challenge the decision.
What is the average turn around time for prior authorization? ›Simply submitting a prior authorization to a payer can require 30 to 60 minutes, and decisions may take up to two weeks to return.
How long does it take for authorization to go through? ›How Long Does a Prior Authorization Take to Get? Once your physician submits a request for prior authorization, a decision is usually returned in several days. In some instances, the initial request may take as long as a week, and appeals may take even longer.
Why do I suddenly need prior authorization? ›This means we need to review some medications before your plan will cover them. We want to know if the medication is medically necessary and appropriate for your situation. If you don't get prior authorization, a medication may cost you more, or we may not cover it.
Why is it important to get preauthorization if the patients insurance requires you to do so? ›An approved pre-authorization is not a guarantee of payment, but it is a good indication of your health plan's intentions to pay for the service or medication. As well, if you do have an approved preauthorization, your insurance is not promising that they will pay 100% of the costs.
What is the process by which providers obtain payers approval before ordering procedures or drugs called? ›Prior authorization—sometimes called precertification or prior approval—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.
What is an example of carding? ›Examples of Carding
Carding generally involves the purchase of gift cards which are then used to purchase gift cards which can then be spent on relatively difficult to trace goods. Often the goods are then re-sold online or elsewhere.
Gold Patients
Patients nearing the end of their life deserve the best care - the 'gold standard' of care. That means high quality, reliable and consistent support provided by frontline teams, as well as those that specialise in this area.
Under TDI rules (i.e., 28 TAC §19.1730(10)) a “gold card” or “preauthorization exemption” is “a privilege obtained [under Texas law and TDI rules] in which a physician or provider is not subject to a preauthorization requirement that otherwise applies with respect to a particular health care service.
What does gold HMO mean? ›A gold health insurance plan is a type of individual & family health insurance policy that covers 80% of covered health care costs with the policyholder paying the remaining 20%. The percentage you're responsible for consists of the deductible, copayment and coinsurance payments.
What is white card method? ›
With this information, thieves can make their own ATM cards using stolen account numbers. It's known as “white card” fraud because the stolen data are put onto the backs of blank, white plastic cards that look like credit cards.
What are dumps scamming? ›A credit card dump is when someone makes an illegal and unauthorized digital copy of a credit card. Credit card dumps have existed for many years. However, they're becoming increasingly popular and more widely used due to the increase in identity theft, credit card theft, credit card forgeries, and other cybercrimes.
What are the 2 types of carding? ›- Roller and clearer card.
- Stationary flat card.
- Revolving flat card.
Use of GSF Needs based Coding
Red colour coding signifies last days of life, amber – deteriorating, green – decline/ unstable/ advanced disease.
The AMBER care bundle encourages regular review of a patients care and ensures that patients, or with their permission, their families are involved in decisions about their care. This may be decisions about treatment, or discussions about what they would like to happen in the future.
Is gold used medically? ›Gold is used most often to treat rheumatoid arthritis. It is sometimes also used to treat juvenile rheumatoid arthritis and psoriatic arthritis. Gold appears to work best in the early stages of arthritis but it may be effective in anyone with active joint pain and swelling.
Can a physician accept a gift card from a patient? ›The AMA's policy notes that physicians should never allow a gift or offer of a gift to influence the medical care that they provide to those patients.
What is Texas House Bill 3459? ›Under House Bill 3459, a physician who has had 90% or higher prior authorizations will be able to earn a gold card. In addition, this gold card is continuous, meaning a doctor does not have to obtain it each year. However, a gold card can be rescinded if a doctor has not kept its 90% rate.
What is the Texas House Bill 3459 prior authorization? ›Under Texas House Bill 3459 (HB3459), providers may qualify for an exemption from submitting prior authorization requests for specific health care service(s) for all fully insured (TDI is indicated on the ID card) and certain Administrative Services Only (ASO) groups.
Is Gold health insurance worth it? ›Deductibles — the amount of medical costs you pay yourself before your plan pays — are usually low. Good choice if: You're willing to pay more each month to have more costs covered when you get medical treatment. If you use a lot of care, a Gold plan could be a good value.
Is HMO better than medical? ›
Generally speaking, an HMO might make sense if lower costs are most important and if you don't mind using a PCP to manage your care. A PPO may be better if you already have a doctor or medical team that you want to keep but doesn't belong to your plan network.
How much is the deductible for a Gold plan? ›Gold (and Platinum) plans do not have deductibles. Coinsurance is your share of costs for a covered health care service. It's calculated as a percentage. For example, under a Gold plan, you would pay 20 percent of the total cost of a wheelchair or oxygen tank, and your plan would pay for the remaining 80 percent.