One of the biggest health insurers in the US, UnitedHealthcare, will start requiring doctors and consumers to get authorization before common treatments on June 1.
Included in this are specific colonoscopies and examinations of the throat, stomach, and digestive tract with scopes. The new policy is being opposed by gastroenterologists who argue that it will result in medical delays, possible patient harm, and higher administrative costs.
UnitedHealthcare’s Prior Authorization Policy
Prior authorizations, according to UnitedHealthcare, are required to prevent the use of superfluous medical services and guarantee that patients receive quality, reasonably priced treatment.
The policy won’t have an impact on the preventive screening of colonoscopies for colon cancer that are advised for persons over 45.
Prior authorizations can reportedly be accomplished within two days, according to UnitedHealthcare.
Significant overuse or unnecessary use of non-screening gastrointestinal endoscopic procedures has been demonstrated in multiple clinical trials, which may expose our members to needless medical risks and increased out-of-pocket expenses.
In the upper and lower digestive tracts, overusing non-screening endoscopic treatments can actually put patients in danger and compromise their safety.
Also, there are concerns about whether screening asymptomatic, low-risk people for some malignancies is cost-effective.
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Medicare’s Coverage Policy: Cost-Effectiveness and Reversal
There is, however, a great deal less disagreement over the necessity and affordability of testing people who are at high risk for colorectal cancer.
In fact, clinical practice guidelines have long included recommendations for high-risk individuals to undergo monitoring and diagnostic colonoscopies.
In addition, surveillance colonoscopies are economical for patients who have a high risk of colorectal cancer.
Importantly, Medicare had a relatively similar coverage provision up until last year, although it was severely criticized and later changed.
The Cologuard test, for example, is used to periodically screen persons 45 years of age and older who are at average risk for colorectal cancer by identifying specific DNA markers and blood in the stool. Historically, Medicare would cover the cost of this test.
Nevertheless, Medicare wouldn’t necessarily pay for a second colonoscopy if the test result was positive.
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