Dealing WIth New Insurance Policies For Colonoscopy
- Gastroenterologists experienced a mix of fear, shock, and outrage upon discovering UnitedHealthcare’s decision to impose prior authorization as a requirement for numerous colonoscopies. This controversial and intricate process has caused concern among medical professionals.
- Your health insurance provider may require prior approval for certain treatments and medications under your medical and prescription drug plans.
- Effective from June 1, the change implemented by the health insurer mandates that United members seeking surveillance and diagnostic colonoscopies for cancer detection must obtain approval from United or face the option of paying for the procedure themselves.
SurvivorNet spoke with Dr. Tiago Biachi, Medical Oncologist and Associate Member at Department of Gastrointestinal Oncology at Moffitt Cancer Center, about this disconcerting news.
Colonoscopies Types
Read More- Screening colonoscopies are considered the "gold standard" procedure to screen colorectal cancer and are performed in asymptomatic patients.
- On the other hand, a diagnostic colonoscopy is performed in order to evaluate a symptom, commonly bloody stools, anemia, positive stool test, change in bowel habits, unintentional weight loss and others.
- In addition, a surveillance colonoscopy is indicated in those patients with past history of colon cancer or with conditions that predispose to cancer, as inflammatory bowel disease, previous high-risk polyps or genetic syndromes.
What Is Prior Authorization?
Prior authorizations, also known as pre-approvals or pre-authorization, are requirements set by health insurance companies that mandate obtaining approval before certain medical treatments, procedures, or prescription medications can be covered. “Any prior authorization policy reduces physician autonomy. Daily US physician are overwhelmed with excessive bureaucracy, P2P calls and letters reducing physician-patient interaction time.” – added Dr Biachi.When a healthcare provider recommends a treatment or medication that falls under the insurance plan’s prior authorization criteria, the healthcare provider or the patient is required to submit a request to the insurance company. The request typically includes detailed information about the patient’s condition, the proposed treatment or medication, and supporting documentation such as medical records or test results.
The insurance company then evaluates the request to determine if the treatment or medication meets their criteria for coverage. This evaluation process ensures that the requested service is medically necessary, appropriate, and cost-effective. The decision is based on factors such as the patient’s medical condition, the effectiveness of alternative treatments, and the insurance company’s specific coverage policies.
If the prior authorization request is approved, the insurance company will provide confirmation, and the treatment or medication will be covered as specified. However, if the request is denied, the patient or healthcare provider may need to explore alternative treatment options or consider filing an appeal to challenge the decision.
Prior authorizations are intended to manage healthcare costs, promote appropriate use of resources, and ensure that patients receive the most effective and necessary treatments. However, they can sometimes be seen as burdensome or time-consuming for healthcare providers and patients, as they can delay access to needed care.
What's all the fuss about?
Physicians say that requiring prior authorization will make it more difficult for patients to get endoscopic procedures, particularly cancer diagnostic and surveillance procedures, in a timely fashion. These make up roughly half of the procedures that gastroenterologists perform.
Although UnitedHealthcare has set a general expectation of completing prior authorizations within a two-day timeframe, physicians argue that this is seldom the reality.
“Of course, 2 days would not affect patient care in the vast majority of cases. However, we will be sure about the real time only after implementation. Also, the bureaucracy behind this new system and time spent filling orders and letters is always concerning.” – said Dr Biachi.
What Is a Colonoscopy?
A colonoscopy is a medical procedure used to examine the inside of the colon (large intestine) and rectum. It is performed by a gastroenterologist, who uses a long, flexible tube called a colonoscope to view the lining of the colon. The colonoscope has a camera and a light at its tip, allowing the doctor to visualize the colon and identify any abnormalities, such as polyps, ulcers, or signs of cancer.
During a colonoscopy, the patient is typically given sedation to help them relax and minimize discomfort. The colonoscope is gently inserted through the anus and advanced through the colon while the doctor carefully examines the colon lining. If any abnormal tissue or polyps are found, they may be removed or biopsied for further examination.
Colorectal Cancer Screening
A screening test is used to look for a disease when a person doesn't have symptoms (when a person has symptoms, diagnostic tests are used to find out the cause of the symptoms).. There are several easy steps you can take to decrease your risk of developing colorectal cancer. According to the American Cancer Society, the most important thing is getting a colonoscopy starting at age 45. This applies to both men and women. Many colon cancers can be caught on colonoscopy even before they develop, or when the polyps (a clump of cells on the colon that may later grow into cancer) are small enough to be removed without surgery. In fact, colonoscopy for screening of colon cancer is so effective that the incidence of this disease is actually decreasing.
Who Should Undergo Screening?
The Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force recommend that adults age 45 to 75 be screened for colorectal cancer. Patients with other risk factors such as family history may benefit from earlier screening. Colonoscopy for screening in average risk patients was approved by CMS for Medicare beneficiaries in 2000 and is almost universally covered by most private insurance carriers.
Alternatives to Colonoscopies
Colonoscopy is the gold standard when it comes to detecting and preventing colorectal cancer, especially for those with a family history of colon cancer or a history of inflammatory bowel disease. But while it's the best preventive method, many people hesitate to have a colonoscopy often fearing the test preparation or the invasiveness of the procedure.
There are colon cancer screening tests available:
- Fecal occult blood test: fecal occult blood test involves analyzing a stool sample (poop), for blood. Occult blood means that you can’t see it with the naked eye. Occult blood in the stool may indicate colon cancer or polyps in the colon or rectum though not all cancers or polyps bleed. One of the most performed tests is the guaiac-based fecal occult blood test (gFOBT). It uses the chemical guaiac to detect blood in the stool and it has to be done once a year.
- Fecal immunochemical test (FIT): it uses antibodies to detect blood in the stool and it’s also done once a year.
- Stool DNA test: this test checks for blood and specific DNA in a stool sample, which could indicate the presence of colon cancer.
- Virtual colonoscopy (CT colonography): virtual colonoscopy is a special X-ray examination of the colon using low dose computed tomography. The procedure does not require sedation. However, as with colonoscopy, a person will need to use medications or an enema to clear the colon beforehand. During the procedure, a healthcare professional will inflate the colon with air to provide a better view.
You and your doctor should decide on the method of screening based on a discussion of the benefits of each technique, its possible complications, costs, availability and individual's preference.
Colorectal cancer
Colon cancer is a type of cancer that affects your large intestine (colon) or the end of your intestine (rectum). Your doctor might call this type of cancer colorectal cancer. It’s is one of the most common cancers worldwide. In the United States, 147,000 individuals received a diagnosis of the disease in 2020, and 53,200 died from it.
Most patients with colorectal cancer are older than 50 years of age at diagnosis.
Men have a higher risk than do women.
Most colorectal cancers develop from benign polyps (abnormal lumps) through a series of genetic changes that take 10 – 15 years. Polyps are very common: about half of individuals 50 years of age and older have polyps.
Detection and removal of colorectal polyps by colonoscopy hinders progression to colorectal cancer. Because only individuals who get a disease can die from it, the reduction of colorectal cancer incidence by adenoma detection and removal through screening leads to reduced mortality associated with colorectal cancer. In addition, screening may detect cancers at an early stage and thereby reduce mortality.
In order to better understand the disease, SurvivorNet has put together a list of colon-cancer-related terms to help you or a loved one should a diagnosis arise. Furthermore, we know that the diagnosis of a cancer can be overwhelming. So we created a specific page with several questions you should ask your doctor.
Questions to Ask Your Doctor
- Do I need to get a screening test for colorectal cancer?
- If my insurance plan won’t cover it. What should I do?
- Are there other screening test(s) do you recommend for me? Why?
- How do I prepare?
- Do I need to change my diet or my usual medication before taking the test?
- Will it be uncomfortable or painful?
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