Welcome. The American Society for Gastrointestinal Endoscopy appreciates your participation in this listening session on key issues regarding UnitedHealthcare's Advanced Notification Program. My name is Eden Essex and I will be the announcer for this presentation. Before we get started, just a few housekeeping items. There will be an open forum at the close of the presentation. Questions and comments can be submitted at any time during this session by using the Q&A function. During the open forum, you may raise your hand if you wish to offer comments verbally and we will unmute your line. Please note that this presentation is being recorded and the recording will be on GILeap, ASG's online learning platform, in the coming days. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to introduce our moderators for this session, Drs. Colleen Schmidt and Joe Vacari. Dr. Schmidt practices at the gastrointestinal specialty arm of Galen Medical Group and is its past president. She has served on committees and boards for local and national organizations. Notably, Dr. Schmidt is a past president of ASGE and previously chaired the Society's Health and Public Policy Committee. She also serves as vice president of the GI Quality Improvement Consortium and is chair of the ASG Foundation. In addition to his clinical practice, Dr. Joe Vacari served as managing partner of Rockford Gastroenterology Associates for 13 years. He has served on numerous National Professional Society committees. Notably, Dr. Vacari currently serves as a counselor on the ASG Board of Governors, co-chairs the ASG Value of Colonoscopy Task Force, as well as the Society's Advanced Practice Provider Task Force, and was the previous chair of ASG's Practice Operations Committee. He also serves as a director of the GI Quality Improvement Consortium. I will now hand the presentation over to Dr. Schmidt. Thank you, Eden, and thank you all for joining us this evening. Tonight's session will focus on key issues regarding UnitedHealthcare's Advanced Notification Program, which directly impacts reimbursement and administrative burden of practices. The purpose of this listening session is twofold, to raise awareness of how this program could impact your practice and to hear from you, your thoughts and your concerns, and to further inform the Society's advocacy efforts. First, to bring us up to date on ASGE's advocacy efforts thus far, I will turn to Dr. Bruce Hennessey. Dr. Hennessey is a gastroenterologist and the managing partner at Ohio Gastroenterology Group, a 36-physician, single-specialty gastroenterology group with five endoscopy surgery centers. He is the current chair of ASGE's Health and Public Policy Committee. Bruce, the floor is yours. Thank you, Colleen, and thank you to everyone who is participating tonight. Just to bring you up to speed on what has transpired over the last couple of months with UnitedHealthcare, they announced in the spring of 2023 that they would be implementing a prior authorization program for just under 50 percent of all of the endoscopy codes, really covering all the outpatient endoscopy that's done in the United States. The ASGE, along with the ACG and AGA, called UHC, asked for meetings with UHC, which they eventually agreed to, where they stated that they had data showing that there were both geographic variations and also over-utilization of endoscopy throughout those regions. UHC, repeatedly during this time, refused to give the data to the societies in support of their prior authorization program. As a result, the ASGE, ACG, and AGA all gathered their support and launched advocacy efforts to try and stop the implementation of the program. Less than a week before implementation, UHC reached out to the societies, asked for a meeting, and then asked the societies to agree to replace the prior authorization program for an advanced notification program. The societies, again, stated that they would not be strong-armed into agreeing to a lesser program and refused. UnitedHealthcare went ahead on June 1st and started the advanced notification program. The advanced notification program is similar to a prior authorization program, but it actually doesn't make a determination as to medical necessity or providing the prior authorization. The goal of this, we believe, is to gather the data that will be used to support a prior authorization program that's either implemented later in 2023 or early 2024, and it'll also be used to support their gold card program in whatever manner they choose to implement it. I think it's important to note that what became apparent is that the data UnitedHealthcare claimed to have regarding geographic variation and overutilization, they probably obviously did not actually have. The program was believed to be part of a new series of programs that payers are using by using either an algorithm-based program or AI to review codes and review authorizations and then making a computerized determination as to whether the procedure would be approved and then sending those to a physician or provider reviewer, which is required with a recommendation of denial, and then the providers are able to deny large batches of procedures at one time, which allows them to be efficient because if they had to actually review each case, they wouldn't have enough providers, wouldn't be able to review enough cases. So AI and these algorithms are really what allows them to efficiently deny large volumes of cases. One of the beneficial parts of this that has occurred is that we've been able to raise some awareness in Congress, and Congress has made inquiries regarding the prioritization practices of the major payers, and as a result, CMS has actually proposed regulations to streamline the prior authorization program, which hopefully will help in terms of prioritization in other areas. I think it's important to remember that this does not mean that prioritization for endoscopy procedures is going away or has gone away. It's really been delayed for a short period of time while UHC actually collects data using the advanced notification program. It's also important to note that the advanced notification program is voluntary, so no one is under any obligation to provide UnitedHealthcare with the data, even though there are many practices that are doing the advanced notification already. It may be beneficial for some groups or some providers if they are eligible for the Gold Card program, but that will probably only cover about 10% of providers, so it's a rather small number. The ASGE is engaged in the continuing advocacy efforts, and we hope to continue to fight the prioritization for endoscopy codes and make sure that the UnitedHealthcare and other payers have real data to justify the prior authorization process going forward. Well, thank you, Bruce. We all certainly appreciate that very nice update and outlining, especially outlining the advocacy efforts by our GI societies. That provides some very helpful context as we move on to our next segment. Now we will hear perspectives from three ASGE members on factors that influence their practices' decisions on whether to participate in this program. Represented among the three are a medium, large, and small practice, and that will be the order of presentation. We'll begin with Dr. Inessa Heickes. Dr. Heickes is a managing partner with Vanguard Gastroenterology in New York City and a member of the Kipps Bay Endoscopy Center. Dr. Heickes is an alumnus of the ASGE Leadership, Education, and Development Program, and she currently serves as chair of the AHG Practice Operations Committee. Inessa, we look forward to hearing your perspective. Good evening, everyone. I'm Inessa Heickes, representing Vanguard Gastroenterology in Manhattan, and thank you for the opportunity to share our practice perspective on the UnitedHealthcare Advanced Notification Program. At Vanguard Gastroenterology, we are a single specialty practice in Manhattan with a team of 11 dedicated gastroenterologists. We provide comprehensive care to a diverse patient population, catering to individuals of all ages with various gastrointestinal conditions. When considering participation in the UnitedHealthcare Advanced Notification Program, we carefully weigh the potential impact on patient care, practice operations, and financial aspects. Our primary concern is the potential, of course, the potential administrative burden associated with the program. We want to ensure that participating won't lead to excessive paperwork or delays in patient care, and we want to balance utilization management and timely access to care, because this is crucial. Transparency in evaluation criteria is another concern for us. We believe that clear and fair criteria are necessary for assessing eligibility for Gold Card Program, and the criteria should align with evidence-based medicine, reflecting the quality of care that we're providing. We're also concerned about the limited input from gastroenterology community during the program development, and collaboration between the providers and payers is vital to create the program of that account for the complexities of delivering that optimal patient care. So, if we choose to participate, we anticipate potential changes in our staff requirements, additional resources that will be necessary to handle administrative tasks such as processing notifications, tracking documentation, ensuring effective communication with UnitedHealthcare staff, and maintaining a seamless workflow, and exceptional patient care as our priorities. So, we'll carefully assess the workload and consider hiring staff members with expertise in navigating the program and learn about these program requirements to ensure the efficient practice operations and delivery of quality care. So, in a summary, participating in the UnitedHealthcare Advanced Notification Program presents both challenges and maybe opportunities. We have concerns about administrative burden, transparency, and evaluation criteria, limited input from GI community, and potential impact on patient access to care. So, effective communication, transparency, and ongoing evaluation are key to address these concerns if we are permitted to participate in that process. Regular assessments and feedback that will help to identify areas for this improvement, ensuring that the program evolves based on the need and the expertise of a GI community. But we do appreciate ASG's strong advocacy on behalf of our professional community and the collaborative effort with other societies, their dedication representing our concerns truly invaluable. So, thank you so much for your attention, and we look forward to contributing to the ongoing discussion and advocacy efforts surrounding this issue. Thank you. Thank you, Inessa. Next up, we will hear from Dr. Jim Weber. Dr. Weber is a gastroenterologist and the founder and CEO of GI Alliance, a physician-led and majority physician-owned GI practice management company providing services to over 800 independent gastroenterologists operating in 15 states. Jim, we look forward to hearing your perspective. The audience is yours. Thank you very much, Joe and Inessa. Nice to hear your perspective. Bruce, very nice summary of the situation, and I, too, want to thank ASGE and our other societies. We, as we looked at this, honestly, I think it was said that I don't really see a lot of difference in advanced notification versus prior authorization other than just flat-out denials. It was interesting, Bruce, you talking about their automation. It's not the same way on our side where each of our schedulers and our staff have to manually put in the same data that's already been submitted, taking about five minutes per case and doing, having to do, you know, 50 to 60 cases per day, adding up to a lot of work hours. All of our managers are already asking us to hire more staff in a very difficult environment to hire and to maintain schedulers, as all of you know, very frustrating and time-consuming and really clearly unnecessary when we know that all of us are following the guidelines and that 99 plus percent of all these procedures would go through. They certainly are doing this as a way to gather data at our expense and our time to hopefully obtain this mysterious gold card, yet none of us really know what a gold card is or what that will provide, and it would be very disappointing if all of us do this and only a small number of people are actually granted a gold card to not have to be subject to prior authorization. My biggest concern is that this is going to delay or inhibit access to care to patients, which is all of our goal to try to care for these patients, and the patients they're actually putting this in place for are those that are at higher risk, those that have a history of colon polyps, those that have symptoms that could be related to colon cancer, and by making it more time-consuming and problematic for our staffs to get these people scheduled, it is clearly a, well, it is an act business decision made by a very powerful payer who controls the patients and the paycheck and is playing doctor on many occasions, honestly, and doing it for their financial gain but not for the well-being of the patients, which I think all of us are trying to do. In our practice, we just did, Joe did a very nice summary. We have over 800 doctors in 15 states, and we work out of 130 endoscopy centers doing over 120,000 procedures per year just for UnitedHealthcare. UnitedHealthcare alone accounted for over $125 million in revenue from these procedures last year for our practices, and it provided really life-saving and life-changing care for these patients, and I'm very concerned that if this preauthorization goes through, patients that need access of care the most were going to be denied. I think we are going to go through the process and see what it does and try to get the data. I'm excited that our societies and other groups are working together and sharing this data to try to make sure that we are not further handcuffed in taking care of our patients. Again, I applaud the ASGE and your efforts, and I am a resource to all of my colleagues throughout the ASGE and the GI community if we can be of assistance as well. Hopefully, we get through this and we can continue to care for our patients in the way that we want to. Thank you for your time. Thank you very much, Jim. Now, we'll hear from Dr. Mazen Jamal. Dr. Jamal is a gastroenterologist and founder of Oceana Gastroenterology Associates. He currently serves on the ASGE Practice Operations Committee. Mazen, we look forward to hearing your perspective, and the floor is yours. Thank you. Thank you very much for allowing me to participate in this very important conference over this very controversial issue of prior authorization. Let me first tell you about our practice. We have a small practice of four gastroenterologists and four middle-level providers. In terms of working with UnitedHealthcare, we do work with Optum. Optum is the owner of many practices in Southern California. In fact, Optum, which is owned by UnitedHealthcare, is a dominant player in the Southern California market, and they have more than 2 million lives. We see 50% of their patients in our area. In terms of UnitedHealthcare PPO, it represents less than 10% of our practice. Now, advanced participation, in our opinion, it's not a good thing. Prior authorization is much better. Now, I say that because the market in Southern California is infiltrated with HMO. All the practices in Southern California has over 80% HMO practices. So we already have a high cost just doing prior authorization in every procedure that we order. Now, in terms of prior authorization with UnitedHealthcare, we decided not to work with them approximately two weeks ago. In fact, we terminated our contract with them because it's not just they're demanding prior authorization, but they are demanding medical record in every claim we submit, and they deny every other claim. So based on that, the market in Southern California is different from the market nationwide, and advanced participation, in our opinion, is not a way to move forward with it. As everybody mentioned, the cost of running a practice has went up by over 50%. It is difficult to find employees. Many of the practices in Southern California are using virtual employees from outside this country. So in summary, I do not believe that UnitedHealthcare advanced participation is something we will accept, and we appreciate ASGE getting involved, and hopefully prior authorization will be less costly to all the practices. Otherwise, it will be very difficult to maintain the overhead that's going up every day. Thank you very much. Amazing, thank you so much for that very, very interesting perspective, and thank you, Inessa and Jim, for sharing your observations from different types of practice as well. Joe and I would like to get a few more insights from all of you before we move to the open forum, and we do want to encourage the participants to submit their questions or observations according to the instructions Eden laid out at the beginning of the discussion and listening session. We have some questions prepared, but we're always eager to hear from the audience. The first question for our panelists does have to do with our resources. Understanding, perhaps, that a gold card status, whether you're in or not, is likely not given in perpetuity. How do we manage our staffing to participate in this program, whether or not we need to get to the prior notification, gold card status, or status quo? Inessa, why don't we start with you? It's a very good question. So it was really interesting to hear perspective of Dr. Jamal. So, but for instance, in our neck of the woods, our insurance payer mix is such that UnitedHealthcare represent close to 30% of the population that we serve. So it seemed like it's strong enough strongly encouraging collaboration with that program in the hope that you're gonna get that reward because we do provide high quality care. We are trying to do all the required things, follow all the guidelines, and we're getting very few denials. So there is always a hope that you're gonna be that gold card holder. Having said that, again, weighing how much resources you have to input to actually get to that final destination, if it's not a hallucination, if it's not an illusion, makes you wonder and question, again, the transparency of the process. That's why I think it's admirable effort on the behalf of our society, Dr. Hennessy in particular, our sister organizations that really engaging in that discussion because it seemed that the bottle is unmatched. So, and I think there is a tremendous geographic variability as how susceptible and vulnerable you are to all these changes that imposed on you by a big brother. If I could comment, Colleen, I do think it's a great question. My concern for, though this is not mandatory, I'm very concerned for groups that have a large percentage of UnitedHealthcare like Hennessy and I do that if you don't take the effort to do this, then you won't get a gold card and you'll be forced to do into a pre-authorization program of which you will then definitely need more staffing to do. So, I would say if you're considering doing it and staffing is your issue, you're probably better off to do this upfront and find out what kind of time and effort it takes and spend that money and effort upfront. And then hopefully you get a gold card and it's not that onerous for us going forward. And I can tell you if you don't need a scheduler, we'll take them from you because schedulers are hard to find. So, anyway, I would probably encourage you to not pass up this opportunity, though it's frustrating. Oh, sorry, Colleen. Go on. Yeah, Jim, we'll stick with you for a second and kind of follow up a little bit on the staffing. From a practical standpoint, especially given the number of physicians and support staff you had, what type of or level of training do you envision that you'll need to do for your staff? And again, with a group as big as yours, it's no small task. Yeah, it is no small task. And as we've all said, getting quality schedulers and keeping them in the seats is very hard. And now it's a whole nother layer of complexity that you've added onto it. We do things on a very local and regional level. So it's not like we do it out of some ivory tower in Dallas, but rather it's boots on the ground in New York and Hartford and Seattle and Phoenix, et cetera. So I think that we have a very good training program in-house to do it and certified coders and schedulers and everybody working together collaboratively to do it. I do think, Joe, it's important that you have really quality people and you can't just get somebody that's never done this before to come in and do this now. So it's a great question. And I think it's gonna take the team that you have currently in place to make sure that they get the new people trained and accessible. So that's a tough question though. Thank you for giving it to me. Mason, I know you feel like there's a different ROI in that staff investment. Can you throw your two cents in before we move on to a different part of the topics? Staffing has been very challenging since COVID. I could tell you we are a small practice, but we have over 20 employees. Since COVID hit us, we only had half of our employees staying with us and being loyal with us. And mostly the one that's in the executive levels at the managers. But we hired and fired over 60 employees since COVID hit us. Finally, we decided not to do that anymore. And we went and we did outsourcing outside the country. Right now we have 15 employees outside the country. They do prior authorization and scheduling and they answer the phone and they even send the request for procedures from overseas to the hospital and the surgery center that we participate in. We found that outsourcing has been excellent because those employees been very dedicated and they're coming to work every day. Unfortunately, our employees in this country, they don't wanna work and most of them they call in sick often or they just quit suddenly after you spent three months training them. They don't even give you another three months of work. So that's been really very challenging and it is very hard in Southern California because right now we have a bill that's gonna be passed, which is a minimum wage of $25 for any healthcare employee, which can increase the cost of running business an additional 50%, which is gonna be difficult to sustain. Maybe we'll throw this one out to back to Inessa perhaps. If you are participating in the program, have you experienced any glitches so far? What's been your experience so far? And if Bruce, Jim also, and Maisa wanna jump in with some quick responses, maybe we can go around the table. Yes, the glitches are there. The program is not perfect. The complaints that we get from our staff that we have a volume, as I mentioned earlier, we have 30%, close to 30% of UnitedHealthcare in our payer mix. So now it increased the burden of phone calls and submissions tremendously. And yet when you get the representative, they only take one maximum two authorizations at a time. So that delays the process, that delays the care for the patients, that increases the frustration of the staffs, the patient satisfaction, physician burnout as always. Jim, any comments? I actually agree with her. I mean, it's taken us about five minutes per case and that's if we can do more than one at a time, often restricted what we can do. They want us to use the portal. It works some of the times, it doesn't work some of the time. This goes to your point, Joe, of these people understanding and knowing how to do it and being educated and having the process. And then there's still having peers to peers thrown at us or if they don't have, the computer doesn't recognize the right information or whatever. So it is a very time consuming process right now. And it is very different. We have over 330 offices and it's 330 different ways that it's being done. I can promise you that. Bruce. Yeah, so our experience regarding the time is pretty similar to Jim's. The biggest issue being that, similar to any website or portal that you engage in, you get kicked off, you get some spinning. Four minutes is the best time. It's certainly not the worst. The other thing I would mention here, there's absolutely no incentive on the part of the payer to make this efficient, to make the system work well, to engage the practice. Really the incentives are all built on not providing an efficient service. I mean, that's actually how they're able to save money. And I think if we were rating the insurance companies based on how good their portals and prior authorization systems were, they'd have abysmal ratings, but unfortunately they continue to get larger and continue to collect more dollars. And that's because programs like this really add to their bottom line. Thank you, Bruce. We have a question from the audience. I'd like to go ahead and share with you because I think it's an important observation rather, but the attendee has said, in addition to the issues identified on this call, we would share a rural perspective. UHC had an early version of this running several years ago. We found that our MDs working in rural areas with hospitals as the only option, I'm assuming for site of service, we were penalized. We had to fight for all of them then. This looks like that program on steroids. That kind of begs a couple of questions. One would be, I think there are some demographics that could potentially be even further disenfranchised by this program. And I'm talking about the patients, much less the providers, but a bigger question for the panel, and let's just go in the same rotation, is based on what you see so far, do you think this is really something disguised as a quality initiative, addressing guideline adherence and value, or is this really about the bottom line for UnitedHealthcare, Inessa? You wanna believe in the goodness of the system, but it's very difficult given the lack of transparency, the lack of communication. The very premise of this initiative has not been fully shared with us. So we're knocking on that door, and I don't think the door is opening. So that's why I think the tri-societal effort to make sure that the program really serve some, and bring something positive to the process, as opposed to all this perceived subjective, negative and incentive that serving the interest of the insurance company, as opposed to better serve the population, and ensuring that we deliver in good quality care. So that very question, that very notion is being questioned by a lack of transparency. I think, Inessa, you are nicer than me, or this is clearly a money play on the part of UnitedHealthcare. We called the day that they put this out, and we got ghosted. We did not get a phone call back. We did not get an explanation. We got nothing. And I agree with the comment from our colleague that raised that question, that those with limited access are gonna have more limited access. And this is very, very much a way to restrict access to care to patients, especially those that need it the most. And it's all done because that by restricting access, they pay less claims, and they pay less claims, especially in places where it costs more money, like when they have to go to a hospital in the country or rural setting where that's their only choice. So very disappointing. They did not have data to support this. They're gonna get it from us. They're gonna do it automated, while we have to do it manually with people that we're paying. And again, this is nothing about improving patient care quality. This is all about limiting access and increasing their dollars. It's very disappointing and frustrating. And the one good thing about this, and Bruce will mention this, is I'm proud of our society stepping up. I'm glad the doctors are talking about it. I'm glad the politicians are talking about it, the newspapers, the patients themselves. So maybe this will shine some light on really what's happening and not make the doctors the bad guy, but maybe the payers who really are the bad guy and not us. So a great question. Mason, do you wanna comment? Well, I totally agree with everything that has been said. It's not just limiting access and not decreasing cost, but it's delaying payment and affecting the quality of care. And I agree with everyone. It's about their bottom line. They're the fourth, I mean, they are number four company in the 500 fortune companies. They're over $430 billion, and they still wanted to decrease cost and create a program that will limit access of their patients to screening colonoscopy, which is the most important procedure that we do every day and we save lives. All right. Well, thank you everyone for your perspective and for a great discussion. Now it's time to hear more from the audience and some questions from the audience. So as we begin to take a look at the questions and comments, we'd like to ask a few polling questions that will help support our advocacy efforts to work on your behalf. So thank you, Eden, for the first question. Eden, go ahead and roll the poll questions. So the first question is, do you have a contract with UnitedHealthcare? Yes, no, or maybe you're unsure if you, depending on where you sit in your practice. So about, looks like about 84% yes, about 12% no, and 4% unsure. So good. Data that we can hopefully begin to put together to work on our advocacy efforts. Go ahead and pull up question number two, Eden, and I'll read it. Do you currently have enough information to make an informed decision on participation in you? HC's advanced notification program? Yes, no or unsure. I want obviously more work to be done by all of us. No surprise given the discussion we've had tonight about 14%. Yes, 79% no and 7% unsure. Question three please. Do you have the staff in place? Or would you need to build a program? Build a team to support participation in you HC's advanced notification program. Yes, we have sufficient staff in place. No, we would need to build a team unsure. I do not do not have enough information on it. Yes, we have sufficient staff 7% no. We need to build a team 69% and unsure 24%. I think this is a real concern for everybody. This is a real one of the real concerns that we have to face within our practices. Thank you everyone for your responses and Eden. Let's go ahead and go through some questions and comments that we have that have already come in. Sure, we have quite a few here. The first is considering how integral endoscopy is to the practice of gastroenterology is United Healthcare. Essentially blanket plan, not an equivalent of restraint of trade. Are there legal options that may be worth pursuing? Do we want to hand that to Doctor Hennessy? Yeah, I think that'd be a good one to use considering he's our health and public policy chair and I guess if he needs someone from the bullpen, you have Camille. Well, thank you and let me start off by saying I am not a lawyer nor Rico or antitrust or whatever statute it would be expert but prior authorization has been around for quite some time. It has been used in a blanket fashion. My my suspicion is that if there was a legal route to challenge it through something like restraint of trade, that would have been pursued by the AMA. I mean, AMA is somewhat of a quasi legal organization as much as it is a physician organization, and I expect that that would have been the case, but I still think that's a great question. And I think any opportunities we have to seek you know some type of legal relief from these types of programs we should. I am pursuing so it's a question that that I'll I'll continue to. I'll ask in the future as well. Bruce, just maybe I'll follow up with another question ties into this. As best as you know, can you share a little bit more information about CMS reaction or perspective to this program? Do we know anything? So I think where CMS is is is most concerned. I think it's also follows along with contractional concern is in the manner with which the prior authorization programs are being implemented. The use of of AI or algorithms in order to rapidly create determinations that providers when reviewing can sign off on has made it so it's. It's so cost efficient for payers to. Initiate prior authorization or deny claims with even even small or codes now that I I believe that even though we have payers saying that they're going to reduce prior authorization, I actually think that we're going to see more prior authorization and more of these programs unless CMS creates some types of guardrails that would make providers who deny these for the insurance companies do an actual review of the case. I mean, the biggest issue is that they're able to review, you know, 60 cases, 60 cases in a batch just by following the computerized recommendation. And so I think we will have to have guardrails around this because it's way too tempting for payers to use a system like this in order to deny claims. I mean, they'll when they deny a claim, they only have to be successful. You know 1% of the time before they're already saving money. Thank you, Bruce. Next question, please Eden. Yes, so Doctor Jamal had indicated you know that UHC's PPO was was demanding records and there was a high rate of denial. How long did that go on for and is anyone else experiencing the same? This person writes that they are also in Southern California, but they haven't had the same experience that Doctor Jamal had. Doctor Jamal, could you expand on your experience a little bit more? I'm not so sure. Well, it depends on your billing company. For us in our practice, I look at every claim, believe it or not, and I looked at the trend of every insurance company that we participate in. So if another person in Southern California did not experience the same thing, I would advise him to talk to their billers and review the data himself or herself. But in terms of denial, the denial rate for United Healthcare PPO in our experience for the last four years is over 25%. And for asking for the record, it's 100%. Every patient, especially if it's an inpatient, so they will ask for the records and they will not ask for the whole record. They will ask for one visit at a time, so you have to have a full time employee answering to them. So if you upload to their portal the whole hospitalization, they will only look at one visit and then a month later, they will ask for the second visit and a month later they will ask for the third visit. Then you may get paid after six to eight months, which is bad for any practices. Your AR should not be longer than 90 days. And that's creating a lot of employment for us. That's why it's better not to work with United Healthcare if they're going to implement prior authorization. They're going to ask for the record. They're going to deny your claims because once they deny the claims, you have to go into an appeal process, which is going to cost you more money to get paid. And that's our experience. Any other comments from faculty or not similar experience? All I can say is, I guess I'm glad I'm not in Southern California, but the fact is, I'm glad one of our participants said that he's not having that experience. It is the, I think we discussed how we were concerned about access to care, the increased time and effort of the staff. But we have not seen, I mean, very, very small percentage of denials. Thank you, Jim. Eden, next question, please. Sure. Is there an opportunity for the GI societies to negotiate with United Healthcare to, for the United to bear the cost of the advanced notification rather than having these costs fall on the practice? Bruce, maybe I'll throw that one back to you. So while I think that there's certainly an opportunity to engage UHC, I'm not sure that the societies have the ability to negotiate with UHC on behalf of practices to bear the cost. I think that the goal for the societies should be to make sure that any program that's implemented by a payer is actually in the best interest of the patient, not necessarily in the best interest of the payer, which I think clearly these programs are in the best interest of. I think earlier there was a question regarding whether or not this was addressing quality or whether it was related to dollars. I mean, I think we see that every day. I mean, it wasn't the insurance companies that started measuring people's ADR, withdrawal times, and things like that. That was us. I mean, that was the physicians were interested in the quality of endoscopy for patients. And of all the people involved, I've really only ever found that the physicians are largely interested in the quality of the care provided to patients. I think the insurance companies are interested in the dollars. But I don't think that the societies would negotiate on behalf of practices to help bear the cost. It's really about making sure that any program implemented is fair and appropriate for patients. I agree, Bruce. I would say, though, for anybody who at least has some negotiating power, and even if you don't, you need to ask United or any payer that is putting this upon you and costing you extra time and money, that that needs to be negotiated in the contract. You need to ask for some type of additional amount of reimbursement to cover those costs, because those are real costs, period. Thank you. Eden, next question, please. There's a question here about has anyone actually reviewed the appropriateness criteria for EGD? This person indicates for colonoscopy. They've published it. And like Anthem's preauthorization, you have to enter data about specific indications. So this person is just wondering about the appropriateness criteria. I guess I'm wondering, does it align with the evidence and what we put forth as the societies? And do you get immediate feedback, positive or negative, on this United program? Inessa, any thoughts on that one? That's, I think, what we've been talking about from the beginning, that there is lack of transparency. And it's not necessarily evidenced that there is an evidence-based or based on some kind of a clinical guidelines. So as of now, we have criteria for the payable diagnosis that we've been following. And that's why the rate of denials in our practice is not that high. Having said that, we do see increased number of denials for unclear reasons. So the claims getting denied for unclear reasons. So that increases, again, the burden on the staff. And this is not just with our practice. This is also with academic institution that we affiliated with. Post-COVID, the hospital also noticed, the hospital system noticed about unprecedented, about 25% increase in denials post-COVID compared to pre-COVID era. So something is happening. Claims are being denied. And it's not entirely transparent. And it's not necessarily immediate response that you get and why. Thank you, Inessa. Next question, please, Eden. Sure. And this is one of those million dollar questions. Has anyone gotten any information on what the gold card program will entail? Jim, you're smiling and laughing. I'll throw it to you. Thanks a lot, because I have no clue what it is. So I think it's a candy bar wrapped in a gold foil wrapper that we get to enjoy while we're on the phone with United Healthcare. I have no idea what the gold card is or what it's actually going to do. We all hope what it means is that we get a free pass on prior authorization and that we put in the appropriate data as we did in the past and we get our procedures moved forward without denials. That is the belief that we have and that we're working towards. But I think it is still yet to see what a gold card really entails. I think it's only fair for me to give everyone a hard time, because I think we all know the answer to the question. But does anyone have any thoughts on that or any clue what the gold card will be? I think we have our answer by silence. Joe, I do have one comment about the fact that they're only going to gold card 10% of the providers. I think to me, being said, if you do a high volume of cases, you're unlikely to get a gold card. I mean, the criteria being that if you do more cases than other providers, then you're not going to be part of it. I think 10% I mean, to assume that, does that mean that only 10% of providers are actually doing things the way it's supposed to? I mean, that's atrocious. I mean, just actually publishing that, I think, is ridiculous. Certainly not a quality marker, is it? Eden, I think we still have time for question two. Is that correct? We sure do. So this next one is, this person's interested in if panel members would be willing to connect their practice managers or what other kind of mechanisms do we have for connecting the practice managers to continue communications and share information regarding workflow for prior authorization, successes, struggles, et cetera. How would we like to address that? Yeah, I guess collegiality would be the word. Would anybody on the panel be willing to share if we received information from practices? Perhaps pass along the questions to those on the call tonight. And I think, Eden, you'll have some comments maybe later about follow-up things we may think about. Is that correct? Yeah, we will have some mechanisms that we will address in a little bit. My guess is everyone on this panel, if they receive some requests from colleagues, would be very happy to help. Absolutely. Absolutely. That begs the question, should we create some practice manager corner in our practice operations? Because I think now it's going to be more valuable than ever to have that hub when the managers can communicate with one another. Yep, you may have created some work for your committee, Ines. Always a look out. Next question, please, Eden. The UnitedHealthcare plan is the secondary insurance. Do they follow the policy of the primary plan, or does UnitedHealthcare still require advanced notifications slash prior authorization? I've been picking on Bruce, but does anyone want to jump in that before I pick on Bruce? It's typically the primary. My understanding is that I would agree with Jim. I think it's the primary, at least when I've read through the various material, it's all based on the primary determination. Eden, are we running out of time or time for one more? I'll offer up this comment that came in, too. And for those of you, we appreciate all the comments that came in. Any questions that came in that weren't answered, we will find a mechanism to follow up with you as we are able. But just as a closing comment, this person says, at this point, our office does not see a tool on the UnitedHealthcare portal where you can just provide a notification. It appears that when we notify, an authorization follows. That shouldn't be the intent of notification. Any comments on that person's experience? There is actually a separate menu for the advanced notification option. But it does kick you back and forth from advanced notification to prior authorization. It's very confusing with a lot of redundant and duplicative work. And one of the elements that we've not touched on is that we're asking our administrative staff to give clinical summaries to United as part of this advanced notification process. I'm not sure we entirely know yet what that looks like, in addition to the vast submission of data that they ask for to be part of that advanced notification process. Thank you, Dr. Schmidt. And Dr. Schmidt and Dr. Vickery, we have come to the close of our session. Any final remarks before I wrap us up? This has been a fantastic program, and we'd like to thank you for joining us tonight in the listening session. Now that it's been in effect for a couple of weeks, ASGE does want to hear from you, not only you, but your colleagues, your practice managers, so that you can share your experience, learn, and share what you learn with everyone else on this. I agree. We're going to need to put more work into this. This evening, we've assembled an outstanding group of leaders on the front line of this issue for ASGE. And we'd like to thank these physicians and their practices for sharing their perspectives and how we can engage further. I'd also like to thank Bruce and our ASGE staff for their fantastic advocacy work. And you can believe that we will use what we learned to continue our discussions with UHC and with our sister societies and continue our advocacy efforts. And I think I'll just agree with Colleen on what she said, but mostly on that last piece, and that is the advocacy work. I think this is one of those important and challenging issues. It's very dynamic, with many times unclear information. We clearly are all in this together. We need your help at the societal level to know what's going on in your practices on the ground so that we can best advocate for you, both at the local, regional, and national level, using all our resources, using the media as an advocate, and certainly pushing our agenda in Washington when it's appropriate. So please stay with us and continue to give us information. Thank you to our moderators, our panelists, and you, our audience. We appreciate your participation in this listening session on key issues regarding UnitedHealthcare's Advanced Notification Program. Addressing this issue will be a marathon, not a sprint. So a few things we ask of you on the front line. First, a link to a two-minute survey will appear on screen after you log off. On screen is a screenshot of what you might see. There's two different things you might see. Your responses will further inform our advocacy efforts. So please take two minutes to complete the survey. We are stronger together and we can amplify our voices. Next, along these same lines, please keep ASG informed as your practice navigates this issue. We'll be sending out a follow-up email that will provide mechanisms for feedback as we move forward. We want to create these connections. We want conversations from us to you, from you to us. And we'll look at what we can do to get you to talk to each other, how we can facilitate that as well. Finally, we'd like you to stay attuned to ASG news alerts on this issue and notices about future listening sessions. Again, this is a marathon, not a sprint. So there will be more listening sessions. So thank you again for your time tonight. Have a good evening.

American Society for Gastrointestinal Endoscopy

ASGE

UnitedHealthcare

Advanced Notification Program

reimbursement

administrative burden

prior authorization program

transparency

data sharing