CEO SUMMARY: It may not yet be open rebellion, but UnitedHealthcare faces strong opposition in Florida from physicians- and their medical societies-over the requirement that they obtain pre-notification and pre-authorization when ordering tests listed in UHC’s laboratory benefit management program. Recent rumors say that UHC has exempted some medical groups from compliance with the program. If true, that could further complicate UHC’s relationship with physicians in the Sunshine State who must continue to comply with this program.
IN FLORIDA, A SIGNIFICANT NUMBER OF PHYSICIANS continue to resist efforts of UnitedHealthcare (UHC) to institute its laboratory benefit management program that is managed by BeaconLBS, a division of Laboratory Corporation of America.
Since October 1, 2014, UHC has required physicians to use this new decision support system when ordering lab tests for beneficiaries of UHC’s commercial HMO patients. The program requires them to obtain pre-notification or preauthorization for 82 lab tests.
If the physicians fail to do so, the laboratories performing the tests will not get paid. The physicians who ordered the tests may also face financial penalties assessed by UHC or even expulsion from UHC’s provider network. UHC has suspended these parts of the laboratory benefit management program and has not stated when it will initiate what it calls “claims impact.”
In the latest developments, physicians in Florida told THE DARK REPORT that they and some colleagues continue to refuse to use the system when ordering clinical laboratory tests for UHC’s commercial HMO patients. They say the system is cumbersome, time-consuming and interferes with patient care.
Further, these physicians report that some specialist physicians are sending patients back to their primary care physicians along with the lab test orders. In this way, PCPs can order the tests for patients and get the results back as well. By refusing to order the tests in their offices, these specialist physicians are hoping the PCPs will report the test results back to them.
Along with these objections about the excessive physician and staff time required to order lab tests through the BeaconLBS system, physicians and their medical specialty associations have told officials at UnitedHealthcare that the current design of the laboratory benefit management program infringes on their practice of medicine in unacceptable ways that could negatively affect patient care and patient outcomes. (See TDRs, July 21, November 3, and October 13, 2014.)
This is true of the Florida Society of Pathologists and the College of American Pathologists. Both medical associations have sent letters to UnitedHealthcare asking the health insurer to defer implementation of the program until serious issues affecting patient care can be addressed.
Specifically, in their letters, the FSP and CAP told UHC that the program: a) could affect patients’ access to care and could delay some diagnoses; b) requires unnecessary certification by subspecialists for certain tests; c) has secondary review requirements that infringe on the practice of medicine; and, d) imposes an additional administrative burden on pathologists.
The Florida Society of Pathologists further stated that it “estimates that about 40% of all pathology practices will have trouble meeting the requirements as UHC specifies in this pilot program,” despite the fact that these same pathology groups have been serving UHC’s patients for decades in accordance with accepted medical practice. (See TDR, January 5, 2015.)
Excludes Most Florida Labs
There is another aspect of UHC’s laboratory benefit management program that rankles Florida physicians and is a major issue of concern for clinical labs. Of the hundreds of clinical laboratories serving patients in Florida today, the BeaconLBS “laboratory of choice network” excludes all but 13 labs-and five of those lab companies are owned and operated by LabCorp (which is also the owner of BeaconLBS). Physicians are unhappy about this aspect of UHC’s program, as it disrupts longstanding clinical relationships between physicians and their preferred labs. It also means that patients who have been served for years by their physicians’ preferred labs must now visit one of the 13 labs in the BeaconLBS network.
When asked by THE DARK REPORT about these issues, UnitedHealthcare has provided specific statements. These can be found in the issues dated November 3, 2014, and January 5, 2015.
No Payment For Lab Claims
Initially, UHC intended to begin the “claims impact” portion of the laboratory benefit management program on October
1, 2014. The health insurer and its contracted manager of the program, BeaconLBS, were prepared to refuse payment to labs performing tests when the physician failed to properly obtain pre-notification or pre-authorization for those tests. Physicians not meeting the requirements of the program would be subject to enforcement as described earlier.
As October 1 approached, UHC found itself confronted by a large number of physicians criticizing many aspects of the laboratory benefit management program. The large scale of this criticism is reflected in the letters and communications sent to UHC by such medical associations asFlorida Medical Association, American Congress of Obstetricians and Gynecologists (ACOG) District XII (Florida), the Florida Academy of Family Physicians, the Coalition of State Rheumatology Organizations, American College of Rheumatology, and the Florida Society of Pathologists and College of American Pathologists mentioned earlier.
UnitedHealthcare decided to delay implementation of the claims impact until January 1, 2015. In December, it announced that the claims impact would be suspended until further notice, but that the laboratory benefit management program remained in effect and physicians were expected to meet its requirements when ordering lab tests.
BeaconLBS Sending Letters to Florida Doctors That Tracks Their Non-Use of Lab Test Order System
Here is the text of a letter (left) that was sent this month to a Florida physician by a BeaconLBS official. It tells the physician that he/she has not used the BeaconLBS system, as required, to order lab tests that are included in the UnitedHealthcare laboratory benefit management program. It even attaches a report that identifies the specific tests where the physician failed to comply with the pre-notification requirement.
One issue that has been a major problem for UnitedHealthcare and BeaconLBS as they try to roll out their laboratory benefit management program is the lack of a smooth-functioning interface with the physicians’ EMR systems. Without such an interface, physicians must go into two different systems to order a lab test. At right is a letter that UHC is sending to Florida physicians that shows which EMR vendors are “integrated or soon to be integrated.” Of the top 10 outpatient EMR systems recently identified by Beckers Hospital Review, only Allscripts andeClinical Works appear on the UHC list.
Neither UHC nor BeaconLBS announced a new date for making payment decisions with BeaconLBS. But UHC said it would give physicians 30 days’ notice before implementing the system. The postponement of the BeaconLBS payment-decision start date is the fourth known postponement for the Beacon system and claims impact. Previously start dates were set for September 1, October 1, and January 1.
Two lab directors in Florida have heard that the new start date for making payment decisions is April 15. Elizabeth Calzadilla-Fiallo, Director, UHC’s Public Relations for Florida and the Gulf States Region, denied that a new start date was set. Instead, she said, UHC will give physicians 30 days’ notice before the program goes live.
Beacon Tracks Lab Orders
One new development is that BeaconLBS is tracking each physician’s lab test ordering. As BeaconLBS learns that physicians have failed to use the BeaconLBS system to order the tests, Matt Parise, Director of Operations for BeaconLBS, has written “Dear Provider” letters that ask them to comply with UHC’s requirements. (See sidebar on page 5.)
Another recent development that could be problematic for UHC is whether it is exempting certain physician groups or physicians from the program so that they do not have to participate. After hearing about this possibility from sources, THE DARK REPORT submitted the question to UHC but did not get an answer.
It may be that such arrangements include a non-disclosure clause, meaning neither party could comment on such a carve-out. However, if UHC is exempting some physicians from this program, that would not be well-accepted by physicians under pressure from UHC and BeaconLBS to comply.
Florida Medical Associations Object to UHC, BeaconLBS
IN RECENT MONTHS, physician associations in Florida have sent letters to UnitedHealthcare to express their vigorous opposition to the health insurer’s laboratory benefit management system that is administered by BeaconLBS.
For example, the Coalition of State Rheumatology Organizations said it could not support the implementation of UHC’s Beacon Laboratory Benefit Solutions system “without data supporting the inappropriate use of laboratory testing by rheumatologists.” The coalition also said it “will do all that is necessary to controvert this policy.”
In a letter dated September 11, to UHC’s National Medical Director, Richard Justman, M.D., CSRO President Michael C. Schweitz, M.D., wrote, “We are going to suggest to our members that they investigate all ethical and legal means to resist this policy and we will pursue the reversal of this policy with our state and national societies through every regulatory, legislative, and public means possible.” (See TDR, January 5, 2015.)
Members of the American Congress of Obstetricians and Gynecologists in Florida are just as concerned. In a letter sent September 11 to Linda Stewart, Vice President of UHC’s national lab program, Robert W. Yelverton, M.D., Chair of ACOG’s District XII (Florida), described how ACOG members have expressed those concerns to UHC, he said, but the health insurer has failed to address their concerns.
“…those [issues] highlighted here compel us to request that UHC suspend this test program as a requirement for Florida providers immediately and indefinitely,” Yelverton wrote. “ACOG District XII values its relationship with UHC and recognizes our shared responsibility in improving the quality and efficiency of patient care. However, we view the implementation of the BeaconLBS program, in its current form, as a giant step backward.” (See TDR, November 3, 2014.)