Surveillance and diagnostic colonoscopies and endoscopies could change under United Healthcare

Nikki Sommer, a nurse with Key West Surgical Group, joined Good Morning Keys on KeysTalk 96.9/102.5 FM for Medical Matters this morning.

For folks who have United Healthcare, there is a change coming up on June 1, particularly in terms of endoscopy.

Sommer said, “Endoscopy is the upper scope where Dr. Smith will look into your stomach. That is a diagnostic procedure, which means there has to be a medical need for you to have that procedure. Screening colonoscopies, as you know, over the age of 45, most insurance companies now recommend you have a screening colonoscopy.”

Usually a prior authorization is not needed.

Sommer said, “What a lot of patients don’t realize, usually for any type of elective procedure, even hernia surgeries, gall bladder surgeries, we do have to get prior authorization from your insurance company and that could take some time.”

On June 1, United Healthcare is requiring prior authorization for a diagnostic or surveillance colonoscopy.

Sommer said, “Here’s where it gets a little murky. If you have your screening colonoscopy and you’re told you have polyps and you need to come back in three years, plan on that we will have to get a prior authorization. Then it becomes a surveillance colonoscopy and so they now might require us to get prior authorization.”

If you have any symptoms of rectal bleeding or abdominal pain, don’t put it off because the office might need to get a prior authorization.

Sommer pointed out, “Now they’re going to be inundated. It’s not just going to be us, it’s going to be everywhere else because this is nationwide through United.”

A prior authorization could take hours on the phone.

Sommer said, “My recommendation is if you’re having any type of issues or you know you are up for a colonoscopy due to either being a surveillance, meaning a history of cancer or polyps, or a diagnostic because you have something acute going on, do not put it off because it’s going to take us a little time possibly to get that prior authorization if you have United Healthcare.”

If United Healthcare is your secondary insurer after Medicare, a prior authorization will likely not be required.

Sommer said, “This is more for the commercial plans of United being the primary insurance. That’s who it’s going to affect. It’s usually people under Medicare age. Us working young folks.”

The screening procedures don’t require prior authorization – it’s only diagnostic or surveillance.

Sommer said, “We do have a lot of patients that have United Healthcare. That’s why I wanted to bring this to light. We do have a significant amount of Blue Cross Blue Shield, United and Cigna. They’re kind of the top three down here. Whatever your health plan is, you should know the ins and outs of it. So if there’s an obstacle that’s coming, you’re prepared on how to deal with it.”

Colonoscopies are recommended for anyone age 45 and older. If no polyps are found, you won’t need another colonoscopy for ten years. If you have a polyp, it would depend on the type as to when your next colonoscopy should be done.

Sommer said, “You could have a family history of polyps. You just need to be screened because anybody could have a polyp.”

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