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  • Writer's pictureShelly Asbury

3 payers halting policies after pushback

Humana, UnitedHealthcare and Cigna changed or paused policies this year after receiving criticism from medical groups and other organizations.


Humana

Humana ended a cataract surgery prior authorization policy for Medicare Advantage beneficiaries in Georgia that had been criticized by ophthalmology groups.

The policy ended Aug. 1, about a year after it was first announced, according to an Aug. 3 American Academy of Ophthalmology news release. The academy joined with the American Society of Cataract and Refractive Surgery and the Georgia Society of Ophthalmology to push back against the policy. The groups argued that the "irrational policy caused unnecessary treatment delays and denials for people in Georgia who needed surgery to restore their sight."

UnitedHealthcare

UnitedHealthcare had plans to implement a gastroenterology endoscopy prior authorization policy June 1 but ultimately put in place an advance notification policy for non-screening and nonemergent GI procedures.

Gastroenterology societies and other organizations pushed back against the proposed prior authorization policy, arguing it would result in delays for medically necessary care, add unnecessary paperwork burden to physicians and staff, and may violate Center for Consumer Information and Insurance Oversight recommendations.

Three GI societies — the American Society for Gastrointestinal Endoscopy, the American College of Gastroenterology and the American Gastroenterological Association — spearheaded a May 8 letter to UnitedHealth Group CEO Andrew Witty, asking him to scrap the policy. The letter was signed by 175 organizations, including Rochester, Minn.-based Mayo Clinic, Baltimore-based Johns Hopkins University School of Medicine, the Cleveland Clinic Foundation, the Medical Group Management Association and Los Angeles-based Cedars-Sinai Medical Center.

The American Hospital Association also raised concerns to UnitedHealthcare the day before the policy was set to take effect.

A UnitedHealthcare spokesperson said in an emailed statement that the replacement advance notification policy will "provide an opportunity for physician education and to allow us to collect more data on which physicians should be eligible for our previously announced 2024 gold card program."

The replacement policy has also met criticism, however.

"UnitedHealthcare's slapdash approach to rolling out a policy that will ultimately control patient access to critical, often lifesaving, medical procedures flies in the face of common sense and responsible medical practice," American Gastroenterological Association President Barbara Jung, MD, said in a June 1 statement. "It also indicates that UHC does not currently have data that shows any significant overutilization of critical endoscopy and colonoscopy procedures that would ostensibly justify this program or prior authorization."

Cigna

Cigna delayed the implementation of a policy that would have required the submission of medical records when using modifier 25 for all evaluation and management claims billed with CPT codes 99212-99215 and a minor procedure.

The policy was set to go into effect May 25. Cigna said it will "continue to review for future implementation.

The American Medical Association and more than 100 physician and healthcare organizations asked Cigna to reconsider the policy, saying it would add administrative costs and burden, thereby potentially affecting patients.

The groups said in their April letter to Cigna CEO David Cordani that the policy was "extremely ill-timed and will further hamper healthcare professionals already grappling with clinician burnout, workforce shortages, recovery from the COVID-19 public health emergency and rising practice expenses due to inflation."

Cigna first notified providers about the policy in May 2022, but the company paused implementation that June to reevaluate the requirement after pushback from medical groups. Cigna reintroduced the policy in March 2023.

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