Starting June 1, some Coloradans who need medical procedures using a scope in their digestive systems will have to wait for their insurance company’s approval — a move that could either curb inappropriate care or discourage patients from getting what they need.
United Healthcare, the largest health insurer in the state, will require prior authorization for most digestive procedures using a scope, though not for colonoscopies meant to screen for cancer.
Prior authorization is when an insurance company assesses whether care is appropriate for a patient before agreeing to pay for it, and it’s a perennial flashpoint in the health care system.
Insurers like it as a way to reduce the amount of care that’s unnecessary or even harmful — which they argue saves everyone money — while doctors and hospitals see it as a time-suck that keeps patients from getting treatments they need.
Dr. Larry Kim, a partner in South Denver Gastroenterology, said he doesn’t understand why United Healthcare chose to add prior authorization requirements for procedures that use scopes in the esophagus, stomach and the upper part of the small intestine, as well as colonoscopies that are meant to diagnose or treat a problem in the large intestine.
While most patients will eventually get care, he said, they may spend additional days coping with bleeding or pain while the authorization goes through.
“These generally aren’t controversial types of procedures,” Kim said.
A representative for United Healthcare said scope procedures are overused, however, and that raises costs and places patients at unnecessary risk. While scope procedures are relatively safe, there’s a small chance of injury, infection or complications from anesthesia.
“Multiple clinical studies have shown significant overutilization or unnecessary use of non-screening gastroenterology endoscopy procedures, which may expose our members to unnecessary medical risks and additional out-of-pocket costs,” the company said in a statement. “This is why we are asking health care professionals to align with current evidence-based practices and guidance from gastroenterology-related medical societies to help ensure our members are receiving safe and clinically appropriate care.”
Right now, prior authorization only applies if the customer is getting the scope procedure at a hospital as an outpatient, according to United Healthcare’s website. Starting in June, people who go to freestanding clinics also will need prior authorization. Patients who get scope procedures in an emergency room or urgent care facility, or as a hospital inpatient, won’t need prior authorization, the United Healthcare representative said.
Patients usually don’t have to do anything to get prior authorization, since their doctor’s office and insurance company handle it behind the scenes. The need to get authorization can delay care, though, if the provider and insurer disagree about whether it’s necessary.
Kim said he’s concerned that some patients will just give up if it takes days or weeks to get a procedure authorized. United Healthcare estimated most authorizations are completed in two days, with the option to expedite a review within hours after receiving all necessary information. (Providers and insurers sometimes disagree about what information is needed, setting up back-and-forths that can frustrate patients.)
Some of the procedures that now will require authorization include opening a blockage that’s preventing someone from swallowing, and tying off enlarged veins in the esophagus that are at risk of bleeding, which is a complication of liver disease, Kim said.
“It’s just something that needs to be done,” he said.
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