UnitedHealth Sets April 15 to Start Claims Impact of Lab Program

Pathologists get reprieve on second-opinion rule; two common tests removed from decision support

APRIL 15 IS THE DATE when UnitedHealthcare will begin denying laboratory claims in Florida that do not meet the requirements of its unpopular laboratory benefit management program.

The health insurer sent out notices last month to alert physicians and laboratories that it will implement what it calls the “claims impact” phase of the program. Effective April 15, physicians must follow the procedures in the BeaconLBS decision support program or claims will not be paid for certain laboratory tests. The program applies to laboratory services for fully insured UnitedHealthcare commercial members.

Apparently the strong opposition that many physicians and societies have expressed to UnitedHealthcare has caused the insurer to back down on some aspects of the program. There was some positive news in the announcement. For example, UnitedHealthcare made it easier for pathologists to comply with the BeaconLBS program, saying it would accept a single review from a sub-specialist or a secondary review from an anatomic pathologist for dermatopathology, cytopathology, and hematopathology.

Last year, the Florida Society of Pathology estimated that about 40% of pathology practices would have trouble meeting the second-opinion pre-certification requirement. Pathologists said that few groups in Florida have the size or composition of subspecialists to meet UHC’s requirement.

UHC also said it would extend the deadline for dermatologists who perform in-office pathology services to comply with the accreditation requirements of the College of American Pathologists. UHC did not announce a new deadline for dermatologists, however.

In another change, UHC removed two routine clinical lab tests from the 80 or so tests listed as requiring pre-notification or pre-authorization. The two tests removed from the decision support list were prenatal profile and gestational diabetes, UHC said.

EHRS with Interfaces

To address physicians’ concerns about which electronic health record systems work with the BeaconLBS system, UHC listed the EHRs from the following system vendors as being compatible with its physician decision support system: Allscripts, aprima, eClinicalWorks, Emdeon, HelloHealth, and Advanced Data Systems.

By issuing this announcement, UnitedHealthcare demonstrates its determination to push forward with its laboratory benefit management system. It remains to be seen how clinical labs and physicians in Florida will react to the rejection of lab test claims if referring physicians do not follow the requirements of the BeaconLBS system when the tests are ordered.


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