CEO SUMMARY: Some physicians in Florida are not complying with UnitedHealthcare’s laboratory benefit management program since the claims impact took effect on April 15. Although officials from UnitedHealthcare and BeaconLBS, a business division of LabCorp, state publicly that the program is going well, physicians and several state medical associations continue to voice serious objections to several key elements of UnitedHealthcare’s lab test utilization management program.
SIX WEEKS HAVE PASSED SINCE UnitedHealthcare launched the “claims impact” part of its new laboratory benefit management program and physicians in Florida continue to express disappointment with the program.
“Claims impact” means that, for a list of about 79 clinical laboratory tests that require pre-notification or pre-authorization, UnitedHealthcare will not pay in-network laboratories when they submit lab test claims that do not meet the requirements of the program. For physicians who fail to use the Beacon Laboratory Benefit Solutions system to order these tests, UHC has said that it may assess penalties against them or exclude them from its provider network. (See TDR, March 9, 2015.)
Since the claims impact took effect on April 15, some physicians are not using the program. They do this by ordering clinical laboratory tests without following the protocols put into place by UnitedHealthcare’s vendor, BeaconLBS, a business division of Laboratory Corporation of America. Or, they simply continue to send lab test orders to labs that are not in the BeaconLBS network.
One such physician is Dennis Saver, M.D., a family physician and geriatrician in Vero Beach. He said his practice is not using the Beacon decision-support system. The founder of the 12-physician practice, Primary Care of the Treasure Coast, Saver said neither UHC nor BeaconLBS responded to numerous requests his practice made to establish an interface between the BeaconLBS system and the practice’s EHR system, eClinicalWorks. (See TDR, September 2, 2014.)
“Basically none of the concerns that physicians had when the BeaconLBS program was announced have been addressed,” stated Saver last week. “One promise UHC and BeaconLBS made was that they were going to integrate the Beacon system with most EHR systems.
“By October 1 of last year, BeaconLBS was going to be working with three EHR systems and by December 2014, BeaconLBS was going to be working with
20-something EHRs,” he explained. “That was an unfulfilled promise!
“In our practice, we repeatedly asked for an interface to eClinicalWorks, which is a fairly common EHR system,” he continued. “Then, in March, a UHC rep got back to us saying he was looking into it for us. A few weeks later, he called back to say that BeaconLBS was still working on it but that eClinicalWorks didn’t want to establish an interface until it issued a software update later this year.
Question of Priorities
“I can’t vouch for the accuracy of these statements,” he added. “That’s just what we were told.”
THE DARK REPORT confirmed this fact with eClinicalWorks. A spokesperson from the EHR company wrote that: “We do have an interface [to BeaconLBS] and it will be part of the next product upgrade… It will be released in October.”
Yet, on UHC’s website for the laboratory benefit management program, eClinicalWorks is listed as an EHR system underneath this statement: “You can select from a variety of applications integrated with Physician Decision Support, including the following laboratory ordering systems and electronic medical records (EMR) applications.”
“At this point we do not have even the possibility of working with an integrated system,” observed Saver, who is an Adjunct Clinical Associate Professor at the University of Florida School of Medicine and a Clinical Associate Professor at the Florida State University College of Medicine. “This is one of those situations where the whole issue makes you wonder about whether making these connections is a priority [for the insurer]. If UHC or Beacon has to pay eClinicalWorks to build an interface, you would think UHC or BeaconLBS would be able to insist that the interface be completed by a certain date.
Unable to Evaluate System
“We have repeatedly told both UHC and BeaconLBS that we would like to be able to evaluate their offer to use the BeaconLBS system,” he noted. “But because there is no interface between BeaconLBS and our EHR, we have been unable to evaluate their offer. So, for now, we are not using the system.”
To date, UHC has not denied any claims that Saver’s medical practice has submitted even though the practice has not followed the Beacon lab-ordering rules, he said. It regularly uses its own inhouse office lab to do most tests of moderate complexity, said Saver. If his practice needs to send any lab tests out, it sends them to Laboratory Corporation of America. LabCorp is a laboratory of choice for the UHC program.
In Palm Beach County, a women’s health care practice is also refusing to use the BeaconLBS program because, among other reasons, its EHR system is not integrated with the BeaconLBS system. And, in a notice posted at the clinic’s front desk, this practice tells its patients that neither UHC nor BeaconLBS has provided adequate details about the program. (See sidebar at right.)
A Patient Care Issue
Another practice not using the BeaconLBS system is the Arthritis and Rheumatic Care Center, a four-physician practice in Miami. Rheumatologist Olga Kromo, M.D., said UHC’s BeaconLBS decision-support system is flawed and difficult to use. In her office, the physicians send lab test orders for UHC patients to Quest Diagnostics Incorporated, she said. That way, the tests get done, which is important for her patients. Failure to get accurate and timely lab test results could affect patient care negatively, she added.
“We are still using the work-around with Quest Diagnostics where they offer to perform the lab tests that we request and then they can try to collect from BeaconLBS or UHC,” she said.
Kromo, in an earlier interview with our sister publication DarkDaily.com, was specific about the patient care issues she believes are serious and could be detrimental to her rheumatology patients. These concerns relate to the ordering algorithms within BeaconLBS that do not appear to cover all the possibilities behind a rheumatologist’s reason to order specific lab tests. This is particularly true for those patients who require frequent clinical lab testing as part of their standard of care.
“Among our patients who have lupus and uncontrolled Sjögren’s, which is very common, there is a high risk of developing lymphoma,” Kromo said. “A clinical laboratory test is recommended for timely monitoring of these patients, but UnitedHealthcare says that BeaconLBS must pre-authorize the test before we can run it. If long-established clinical guidelines specify that a test is recommended for lupus patients with Sjögren’s, why should we physicians have to request authorization from a health insurer?”
In this interview, Kromo estimated that, if her rheumatology and arthritis practice were to use the BeaconLBS system, the phlebotomist would need to stay an extra hour to two every day. “Just the paperwork for Beacon takes about 20 to 25 minutes per patient should a patient need lab tests. Because about 95% of our patients need lab tests on almost every visit, it’s obvious how this system disrupts patient flow in our office,” Kromo said.”
In fact, our lab person was so upset about the need to do all this extra work
that she almost quit,” Kromo said. “And this is someone who has been with us for seven years.”
UnitedHealthcare’s laboratory benefit management program has also met with stiff resistance from Florida state medical societies. A primary concern is that the program represents an unwarranted and unsupported intrusion in how physicians practice medicine.
To this point, the Coalition of State Rheumatology Associations wrote a letter to UnitedHealth on September 11, 2014, and stated that: “Requiring trained, certified [physician] specialists to obtain authorization from a less qualified person or entity using a rote, inflexible algorithm is not only unnecessary, but insulting. We are not insensitive to issues regarding the control of medical costs, but absent the provision of data demonstrating the inappropriate use of laboratory tests by rheumatologists, we cannot support, and will do all that is necessary, to controvert this policy.
‘Pursue Reversal of Policy’
“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,” concluded Michael C. Schweitz, M.D., President of CSRO and author of the letter.
UnitedHealthcare and BeaconLBS were asked by THE DARK REPORT to comment on the concerns of rheumatologists and the issues described in the letter from the Coalition of State Rheumatology Associations to UHC. No comment on these points, nor about the integration capability of eClinicalWorks, has been received.
For their part, labs in Florida have “voted with their feet” against this program. Among the hundreds of clinical labs and pathology groups serving patients in Florida, as of last fall, only 13 labs chose to sign agreements with BeaconLBS to be “laboratories of choice” and five of those are LabCorp-the owner of BeaconLBS-and its different lab business units. Only eight non-LabCorp labs chose to participate despite aggressive marketing efforts by representatives of UHC and BeaconLBS to encourage these labs to participate in the program.
Pathologists in Florida Remain Concerned About Claims Denial Phase of UHC & BeaconLBS System
IN MARCH, UnitedHealthcare notified physicians, clinical laboratories, and other providers that it was revising its laboratory benefit management program that BeaconLBS administrates. At the time, UHC said these changes were the result of comments and criticisms from physicians.
Pathologists in Florida got some relief. One original requirement was that pathologists get a secondary review for certain specimens. After the change, UHC said it would accept either a single review from a subspecialist or a secondary review from an anatomic pathologist for dermatopathology, cytopathology, and hematopathology.
Last year, the Florida Society of Pathologists estimated that about 40% of the state’s pathology groups would have trouble meeting this second-opinion pre-certification requirement in the BeaconLBS program. Few pathology groups in Florida have the size or composition of subspecialtists to meet the requirement, pathologists said. (See TDR, January 5, 2015.)
But Brett Cantrell, M.D., FSP’s past president, said that his six-physician practice, Consolidated Laboratory Services at St. Vincent’s HealthCare in Jacksonville, Florida, might not have qualified under the former rules. The group might have needed to arrange for subspecialty review, he said.
He welcomed the change from UHC. “The second-opinion modification is a major concession from UHC and makes this much more palatable from the private pathology lab’s standpoint,” he stated. “A second review of initial cancer diagnosis by another anatomic pathologist but not a subspecialty-boarded pathologist is standard practice in many groups and is not unreasonable.
“The subspecialty retraction was something we pushed hard to achieve, but I suspect United was feeling pressure from multiple sources on that issue, which offered no economic reward to United but did perhaps provide an incentive to utilize certain labs over others,” he wrote in an email. “Single pathologist practices will have to find some arrangement with another practice to meet that requirement but most labs will be able to comply with the review requirement without difficulty.
“While we may feel like celebrating the subspecialty retraction, the reality is we are still left with a cumbersome program that will be fraught with noncompliance by clinicians, leaving the pathology labs holding an unreimbursed bag. What percentage of labs participate will be an economic decision,” he concluded.
The ultimate irony to this story for UHC and LabCorp is that ongoing resistance by physicians to this program could lead to a Florida state law that governs lab test utilization programs such as BeaconLBS. In a story about UHC and BeaconLBS titled “UnitedHealthcare pilot to curb lab costs draws protest,” Modern Healthcare wrote that the “…Florida Medical Association has drafted legislation to block insurers from implementing similar programs. Doctors say complying with the new program takes too much time.”
On this subject, Modern Healthcare quoted Tampa orthopedist Michael Wasylik, M.D., Chairman of the medical association’s medical services committee. He stated that: “Soon we won’t be able to see patients, we’ll just spend all our time documenting everything. It makes me want to puke just talking about it.”
Contact Dennis Saver, M.D., at email@example.com; Brett Cantrell, M.D., at Brett.Cantrell@jaxhealth.com; Olga Kromo, M.D., at firstname.lastname@example.org.
Women’s Health Clinic in Florida Posts Notice to Tell Patients It Won’t Participate in UHC Program
IN FLORIDA, A SIGNIFICANT NUMBER OF PHYSICIANS CONTINUE TO BE DISSATISFIED with UnitedHealthcare’s laboratory benefit management program, administered by BeaconLBS. Some physicians are outspoken about their dissatisfaction. Below is a photograph of a sign posted at the front desk of The Women’s Health Institute on Florida’s east coast. It explains to patients that this physician will not participate in the program and will thus not be ordering lab tests through the BeaconLBS system.
“Recently UnitedHealthcare notified us that… they would be requiring physician’s offices to get 3rd party authorization when Dr. Bernstein orders certain lab tests on its patients. The lab tests in question are mainly standard of care tests, some of which are required by Florida law and others that are part of the recommended care guidelines set forth by ACOG (The American Congress of Obstetricians and Gynecologists). The tests in question include routine Pap tests, STD tests, OB labs, genetic testing, and many others that Dr. Bernstein orders on a daily basis while caring for our patients.
After a great deal of thought we have chosen not to participate with this process. We have informed UnitedHealthcare, LabCorp, and now you of this decision. The main driving factor for our decision has been that the process required for obtaining this 3rd party authorization has not been effectively communicated to us at this time. The few details that have been given lead us to believe that there is currently no plan to provide automation through integration with our EMR vendor. We have requested that UnitedHealthcare reverse their decision to implement this process or at least delay the effective date until an efficient integration with our EMR can be established and proper education and training of our staff has been completed.
Dr. Bernstein will continue to order the lab tests she believes you need based upon her sound, unbiased, and professional judgment. We hope and trust that UnitedHealthcare will fully honor its policy of insurance to you and pay for the lab services within the scope of your policy. Should you experience any feedback from either UnitedHealthcare or LabCorp, please let us know immediately.
The business of healthcare is complex, your office visit need not be.”