This article is an excerpt from a 1,500-word article in the March 21 issue of THE DARK REPORT. Full details of UHC’s battle against out-of-network labs, as well as its plans to begin requiring pre-authorization for genetic testing, are included in the original article, available to paid members.
IN ITS LATEST NETWORK BULLETIN, UnitedHealthcare warned out-of-net- work laboratories not to waive or cap patients’ copayments or deductibles. In the same bulletin, it also announced that it will require prior authorization for all genetic tests later this year.
In a bulletin to providers March 1, UHC says: “Effective Q3 2016, UnitedHealthcare will require care providers to obtain prior authorization for genetic testing for our commercial members. Details on how to request prior authorization, the genetic testing policy to be used in the review process, and other information will be included in a future Network Bulletin newsletter and on our physician portal.”
On the issue of waiving patients’ fees, UHC is specific and threatening. “Some nonparticipating labs attempt to attract customers by waiving or capping copayments, coinsurance or deductibles. Such arrangements undermine the benefit plan by eliminating incentives created to encourage members to choose to receive care within the network and to discourage overutilization of services,” says UHC, the nation’s largest health insurer.
“UnitedHealthcare’s benefit contracts exclude coverage for any out-of-network lab services for which the provider waives the coinsurance, copayments, or deductibles. In addition, routine waiver of coinsurance, copayments, or deductibles may be a violation of the federal False Claims Act, subject to investigation by the Office of the Inspector General and/or any applicable state insurance department’s fraud division,” wrote UHC.
referrals To Network Labs
The bulletin also explains that UHC’s network includes “more than 1,500 clinical reference laboratories.” In-network physicians and other providers “are expected to refer our members to network laboratories for clinical lab and anatomic pathology, unless otherwise authorized by UnitedHealthcare consistent with their participation agreement,” the bulletin says.
UnitedHealthcare officials did not respond to a request for comment.
The warning about waiving patients’ payments is likely a result of leaving so many laboratories out of its network, stated Linda D. Liston, CPC, Director of Managed Care Services for McKesson Business Performance Services.
“UnitedHealthcare gets a lot of out-of-network charges because it won’t give small, local, or regional labs contracts. We know this from our experience with UHC,” she explained.
“When we tell UHC that it is receiving a large number of lab test claims for UHC members in a particular area and that is a reason why it should contract with those local or regional labs, its officials say, ‘We’ve got our national agreement and don’t need another lab or pathology group,” explained Liston, who has served as McKesson’s director of managed care services for 20 years.