CEO SUMMARY: In a letter to UnitedHealthcare, the Florida Society of Pathologists says UHC’s pilot laboratory management program will have a negative effect on patient care by delaying access to care and timely diagnoses of disease. Signed by more than 120 members of the society, the letter lays out inconsistencies in the requirements of UHC’s pilot program that Florida physicians must follow to obtain pre-notification or pre-authorization for more than 80 clinical laboratory tests.
ANOTHER FLORIDA MEDICAL ASSOCIATION HAS COMPLAINED TO UnitedHealthcare about the BeaconLBS laboratory management program.
In a letter sent December 19, more than 120 members of the Florida Society of Pathologists expressed numerous clinical concerns about the program, calling it ill-conceived and saying it will impair physicians’ ability to practice medicine. They also said it would have a negative effect on clinical quality, patients’ access to care, and timely diagnosis for United Healthcare enrollees.
Brett Cantrell, M.D., President of the Florida Society of Pathologists, said FSP members are reluctant to participate in UHC’s laboratory benefit management program, which is managed by BeaconLBS.
“Pathologists believe the implementation of the pilot program as it exists now could have a negative effect on patient care, particularly if—as expected—many pathology groups are unable to meet UHC’s second-opinion requirements for some clinical lab tests,” added Cantrell.
“Pathologists also are concerned that they may not get paid if physicians do not comply with the pre-notification or pre-authorization requirements UHC has implemented for 82 or so clinical lab tests,” he said. “Currently, claims denials under the pilot program have not been fully implemented.
“In particular, the members of the Florida Society of Pathologists are concerned about how the BeaconLBS system will affect the workflow in their offices, their clinical decision-making, and patient care,” said Cantrell. The letter was addressed to Richard A. Justman, M.D., National Medical Director, and Linda Stewart, Vice President, National Lab Program.
Concerns about Patient Care
In the letter, the FSP said its members were concerned about UHC’s laboratory benefit management program, including:
- How it could affect patients’ access to care and could delay some diagnoses;
- How the program requires unnecessary certification by subspecialists for certain tests; • How secondary review requirements infringe on the practice of medicine; and,
- How the program imposes an additional administrative burden on pathologists.
Florida pathologists are not alone in their criticism of the UHC and BeaconLBS program. “Pathologists across the country are watching how UHC has introduced the BeaconLBS program and have expressed concern about it as well,” declared Jonathan L. Myles, M.D., Chair of the Economic Affairs Committee of the College of American Pathologists.
UHC has contracted with BeaconLBS, a subsidiary of Laboratory Corporation of America, to install the system and manage parts of the pilot program.
Pathologists Seek Revisions
The Florida Society of Pathologists asked UnitedHealthcare not to fully implement the pilot program and to make the system less onerous. “The entire pre-notification and pre-authorization end of this program is an order of magnitude more intrusive than anything to which physicians are accustomed,” said Cantrell. “It’s certainly understandable to require pre-authorization for a molecular test such as BRCA, but UHC actually is going in the other direction by asking for pre-notification for routine testing.
“We asked them not to fully implement the program and to retool it. I don’t think the current program is workable,” added Cantrell. “We recognize that UnitedHealthcare, providers, and pathologists can’t go on with business as usual in healthcare. We all have to adjust to the new medical paradigm. But this is an ill-conceived program that UHC needs to modify and then come back to us with something more workable.
“In addition to pre-notification and pre-authorization, physicians are concerned about the need for second-opinion pre-certification because many pathology groups will be unable to meet this requirement,” explained Cantrell.
Pathologists’ Letter to United Outlines Concerns
IN A LETTER SENT RECENTLY TO OFFICIALS at UnitedHealthcare, members of the Florida Society of Pathologists expressed deep concern about United’s pilot Beacon Laboratory Benefit Solutions program. Among the concerns the pathologists cited in the letter were the following:
- The volume of tests for which notification via BeaconLBS must be provided to meet pilot requirements (in excess of 80 tests, some of which are commonly performed cytology) is onerous and the program’s requirements will have a significant effect on the daily workflow of ordering physicians and laboratories.
- The secondary pathology review requirement to be performed by pathologists with subspecialty certification is overly broad and does not reflect current widespread accepted practice, the letter said.
- The secondary review requirement infringes on the practice of medicine.
- There is a potential for delays in ordering tests and providing test results. These delays could affect patients’ access to care.
- There is an additional administrative burden to comply with program requirements.
“The Florida Society of Pathologists estimates that about 40% of all pathology practices will have trouble meeting the requirements as UHC specifies in this pilot program,” Myles said. “For these groups, their size and composition of subspecialists—in terms of the professionals in the practice—will mean they don’t have the staff to meet the requirements set forth by UnitedHealthcare.”
Cantrell is Medical Director for Consolidated Laboratory Services at St. Vincent’s HealthCare in Jacksonville, Florida. His pathology group may not qualify for the BeaconLBS program, he said.
“In my six-man group, for example, we have a dermatopathologist, but we don’t have a second dermpath available for subspecialty review,” commented Cantrell. “If this part of the UHC program remains, our pathology group would need an arrangement to share subspecialty review for dermatopathology. That would cost money, and UHC has not said who would pay for that.
Why Few Labs Have Applied
“A large percentage of pathology groups in Florida cannot qualify for this requirement,” he continued. “However, even those groups that can qualify are reluctant to sign up. That is why very few labs have applied to participate in the BeaconLBS system.”
In particular, Myles said, the second-opinion requirements could negatively affect patient care.
“Many pathology practices may not be the appropriate size to meet the UHC requirements,” he said. “If there are not enough practices to meet the requirements, it could delay diagnoses. That would lead to concerns about how the program could affect patient care.
“And who would bear the cost for that secondary review?” asked Myles. “That’s unclear.”
Second Opinion Is Required
The BeaconLBS system requires pathologists to have a second pathologist review the pathologic diagnosis for certain types of specimens. Morever, the subspecialist pathologists who review these tests must have specific certifications. The College of American Pathologists earlier asked UHC to reconsider these requirements but to date UHC has left them in place.
Cantrell has heard from UHC officials that it is implementing the BeaconLBS system because clinical lab test costs are rising sharply.
“Of course, the aim of the BeaconLBS program is not just to control costs,” Cantrell said. “It’s also about quality. We
don’t stand in the way of improving quality, but we don’t agree on the direction UHC and BeaconLBS are taking with this pilot program.
“In particular, the Florida Society of Pathologists disagrees with the fundamental concept of the need for subspecialty review,” he said. “The American Board of Pathology has gone on record that subspecialty review is an inappropriate use of subspecialty certification. That’s not the intent of subspecialty certification.
“Pathologists want to practice medicine and feel strongly that the subspecialty review requirement is deeply intrusive. I’m a board-certified anatomic pathologist,” emphasized Myles. “In my professional practice of medicine, there are times when it is my responsibility to seek another opinion. However UnitedHealthcare is determining for me when second opinions are necessary—irrespective of my assessment for that need.”
Asking to See Clinical Data
Pathologists, like other physicians practicing in Florida, are asking legitimate questions about why UHC’s laboratory benefits management program has requirements that infringe on long-standing and widely-accepted clinical protocols, be it in primary care, ob-gyn, or pathology, for example.
In particular, those physicians who have voiced these concerns have asked UnitedHealthcare to provide specific information and clinical data that support UHC’s statements that the requirements of the BeaconLBS system for lab test pre-notification or pre-authorization are needed to resolve an unacceptable situation in either patient care or unnecessary healthcare costs, or both. To date, UHC is not believed to have provided such information to physicians as an answer to these concerns.
Pathologists Still Seeking Answers to Questions About UnitedHealthcare and BeaconLBS Program
PATHOLOGISTS HAVE A LONG LIST of questions for UnitedHealthcare about the reasoning behind requiring pre-notification and pre-authorization for 82 clinical laboratory tests, said Jonathan L. Myles, M.D., a pathologist and Chair of the Economic Affairs Committee for the College of American Pathologists.
“What problem is UnitedHealthcare (UHC) trying to solve with this pilot program?” he asked. “Also, why is UHC requiring secondary review for some specimens but not for others? Who will perform these secondary reviews? Why is a health insurer intervening into a pathologist’s scope of practice by requiring secondary reviews irrespective of the pathologist’s medical assessment of the case, and why doesn’t the UHC pilot program address the issue of false negative test results?
“UnitedHealthcare has not said what the real problem is,” noted Myles. “Pathologists need to know that before we can have a successful resolution to the issues and before there can be a successful program to mitigate any of UHC’s concerns.
“What is also unclear is why UHC wants a subspecialist-pathologist to review some cases when these cases are referred from one type of practitioner, yet it doesn’t require a subspecialist to confirm a primary diagnosis on other types of cases,” added Myles.
Lack of Consistency
“In the UnitedHealthcare pilot program, for example, when a lab receives a skin case referred by a dermatologist, both the primary and secondary review needs to be done by a dermatopathologist,” he noted. “But if a skin case is referred from a physician who is not a dermatologist, any surgical pathologist can read that case, at least initially. So there is a lack of consistency in the UHC requirements—depending on what type of professional did the biopsy and referred the tissue.
“Another issue pathologists have with the pilot program is that it focuses on secondary review of malignancies but doesn’t mention any consideration of potential false negatives,” continued Myles. “We are curious about why there is no discussion about false negatives.
“Identifying false negatives is important because those would be diagnoses that would be missed,” he observed. “If they are missed, then ultimately, downstream costs might be increased, not to mention how missing a false negative would affect the patient’s outcome.
Secondary Review Rules
“Yet another clinical concern is the question about who will perform the secondary reviews,” stated Myles. “Routinely, physician-pathologists decide which cases require second opinions and it is within a pathologist’s professional judgment if a case needs a consult from another pathologist before it’s signed out or interpreted.
“In fact, the diagnoses we make as pathologists are within the scope of our licensure and within the scope of services that the American Board of Pathology has deemed us capable of doing,” he emphasized. “That is a major clinical concern for us.
“The entire UHC pilot program is provocative because it raises all these questions that need to be answered,” stated Myles. “Moreover, it is not just pathologists in Florida who are concerned about this pilot program. Pathologists across the country are equally concerned.
“Additionally, the BeaconLBS system also creates an administrative burden on physicians who order any of the 80 or more clinical laboratory tests and on pathologists who must ensure that ordering physicians have taken all the necessary steps for pre-notification and pre-authorization,” concluded Myles. “If ordering physicians do not complete the necessary steps, then pathologists may not get paid.”
Contact Brett Cantrell, M.D., at 904-296-4670 or Brett.Cantrell@jaxhealth.com; Jonathan Myles, M.D., at 813-877-9413.