UnitedHealth Not Paying Lab Claims of Some Docs

One Florida medical group says it is prepared not to renew its contract with UnitedHealthcare

CEO SUMMARY: It continues to be tough going in Florida for UnitedHealthcare and its contractor, BeaconLBS. Efforts to implement the UHC laboratory benefit management program face stiff resistance from some physicians and a number of state medical associations. One primary care group in Vero Beach says payments for its clinical lab test claims have been inconsistent since April 1 because it refuses to use UnitedHealthcare’s Beacon Laboratory Benefit Solutions program when ordering tests for UHC’s commercial patients.

SOME PHYSICIANS IN FLORIDA continue to battle UnitedHealthcare over its requirement that they must order a designated menu of lab tests using the BeaconLBS system.

In fact, UnitedHealthcare has told one 12-physician group in Vero Beach, Florida, that its contract with the health insurer will not be renewed at the end of the year if it does not use the BeaconLBS system when ordering lab tests.

“Since April 1, payment from UnitedHealth for our practice’s in-office lab test claims has been inconsistent,” stated J. Michael Luton, CEO of the group, Primary Care of the Treasure Coast (PCTC).

“On that date, United stopped paying our group for any laboratory tests it submitted from the group’s physician-office laboratory.”

When the group complained, UHC paid some bills but not others, reported Luton. When he learned that the group’s lab test invoices were unpaid, Luton sent an email to UnitedHealthcare asking why. In its response, UHC recommended PCTC register to use the BeaconLBS system and said that if the group did not register with and use the BeaconLBS system, United would not renew its contract with the group for 2016, added Luton. United patients represent only about 8% of PCTC’s patients, Luton said. About 58% of PCTC’s income is from Medicare, and about 20% is from Florida Blue. The remainder is from UnitedHealthcare and other sources, Luton explained.

Managing Lab Orders

BeaconLBS is a laboratory benefit management program that UnitedHealthcare introduced last year for its commercial members in Florida. The program was scheduled to start October 15, 2014, but that date was postponed until January 1, 2015, when United required physicians serving its members in the Sunshine State to use the BeaconLBS decision support system when ordering any of 79 tests on a list UHC publishes on its website. (See TDR, July 21, 2014, and October 13, 2014.)

On April 15, UnitedHealthcare started making claims-payment decisions based on whether physicians followed all of the rules it required for the BeaconLBS system. “But United stopped paying PCTC before April 15,” noted Luton.

Many physicians in Florida have told THE DARK REPORT that using the BeaconLBS system to order any of the 79 clinical laboratory tests is difficult and requires extra time. Some physicians and their state medical associations have voiced similar concerns to UnitedHealthcare and BeaconLBS, further stating that the pre-notification or preauthorization requirements for the designated laboratory tests infringe on physicians’ professional practice of medicine and could lead to patient harm. (See TDR, November 3, 2014, and January 26, 2015.)

“In May we noticed that UnitedHealthcare stopped paying for our lab tests,” explained Luton. “When we asked one of our billing clerks to check it out, UHC said we didn’t submit all the information we were supposed to submit for our claims. We then checked with our claims processing clearinghouse, Emdeon, and they said all the claims were submitted correctly, just as we had been doing for years.

Pending Payment Cuts

“Next, I sent an email to UnitedHealthcare and they explained that they had not paid our lab test claims because we had not registered with the BeaconLBS system,” he added. “We had already told UHC that we wouldn’t use the BeaconLBS system because it didn’t work with our electronic health record system, eClinicalWorks.

“We know from eClinicalWorks that the Beacon interface won’t be ready until the fall when eClinicalWorks does a complete upgrade,” continued Luton. “After we’ve reviewed the upgrade, we will either approve the BeaconLBS system or not. If we don’t approve it, we won’t use it. That was a decision the physicians made.

“But even after we see how it works, I’m not sure it will be worthwhile,” he said. “The BeaconLBS system was demo’ed for
us last fall. We tried to submit a request for a pregnancy test and that request required the physicians to complete a 4- to 5-page report just for one test.

“We told them, ‘That’s crazy. You can’t expect our physicians to go outside of our system to go to the BeaconLBS website to fill out the forms just to order a routine test. That doesn’t make any sense.’ And they replied that they didn’t know why it took so much time. To that, I said, ‘You just saw for yourself how long it takes,” said Luton.

“At that time, several of our physicians looked at how the system works and threw up their hands in frustration,” Luton added. “We don’t have many tests on the BeaconLBS list that we perform here in our lab,” he noted. “But several lab tests that our physicians order frequently are on that list. Given the difficulty and time required for physicians to order in the BeaconLBS system, we are skeptical that any benefits will result from our use of the system.

“We have asked UnitedHealthcare and Beacon to show us the evidence that the lab tests they require to be approved via a point-of-care decision instrument have been misused, but they have never been able to do so,” Luton added.

“At this moment, our physicians have decided not to use the BeaconLBS system until we see how it works with eClinicalWorks, and we are not adding any new UnitedHealthcare patients,” commented Luton. “In addition, we may need to notify our UnitedHealthcare patients that we may not renew the contract next year.”

This is one example of physicians who continue to voice their discontent about the requirements of UnitedHealthcare’s laboratory benefit management program. Rumors continue to circulate that UHC has exempted some large medical groups from the program, but no one is willing to speak on the record about such situations.

UnitedHealthcare, BeaconLBS still Face Strong Resistance from some Physicians

MANY PATHOLOGISTS AND CLINICAL LAB PROFESSIONALS who read comic books during the silver age (1956-1970) may recall the great conundrum often presented in issues of Superman: What happens when the unstoppable force (typically a villain) meets the immovable object (Superman)?

This same conundrum aptly describes the current situation in Florida involving UnitedHealthcare and its contractor, BeaconLBS (a business division of Laboratory Corporation of America) and physicians who care for patients enrolled in UHC’s commercial plans. In this scenario which continues to play out from day to day, UnitedHealthcare is the unstoppable force. Opposing United is a significant number of Florida physicians in medical specialties who are the immovable objects.

Since UnitedHealthcare began enforcing “claims impact” on April 15, 2015, with its laboratory benefit management program that is handled by BeaconLBS, an unknown—but significant—number of Florida physicians have refused to follow the requirements for ordering the 79 lab tests designated for pre-authorization or pre-notification via use of the BeaconLBS system. (See TDR, March 9, 2015.) One example of physician resistance is found at Primary Care of the Treasure Coast, in Vero Beach, Florida. Its 12 physicians have taken a tough stand against using the BeaconLBS system until they can test how it would work in their practice. In an interview with THE DARK REPORT, J. Michael Luton, CEO of PCTC, shared an email exchange he had with Todd Kamenda, Network Account Manager for UnitedHealthcare.

On June 25, Luton wrote: “Dear Mr. Kamenda, I have been forced to write this email (separate letter to follow) due to your lack of responses to the various voicemails my staff and I have left you concerning the [non]-reimbursement of UnitedHealthcare patient’s laboratory payments… We have done extensive testing with our claims processing service, Emdeon, and have found no problem with the data being submitted.

“It is my opinion that these claims are being held due to our failure to participate with the Beacon lab management program,” wrote Luton. “Although there are only 79 lab tests covered by the Beacon program you have elected to withhold all laboratory payments to our practice. This is an unconscionable act on the part of your company.

“…The actions taken by UnitedHealthcare in refusing to pay for laboratory services approved by contract with you forces us to react by closing our practice to all new United Healthcare patients,” said Luton. “UHC has stated that physician participation with United Healthcare programs would be eliminated by refusal to participate with the Beacon program. Should that be your decision and it is immediate, we will abide by it and notify all UHC patients that we are no longer participants with UnitedHealthcare.

Formal resignation

“After discussion by the Board of Directors of PCTC, we believe that you have violated the terms and spirit of our contract, and thus consider this our formal resignation for all Primary Care of the Treasure Coast, Inc., providers from all UnitedHealthcare programs effective January 1, 2016,” concluded Luton.

In response to Luton’s email, Kamenda replied on July 1 as follows: “Hi Michael, Thank you for your patience in allowing me to research this issue further. In terms of the pended claims, we do not pick and choose who we deny claims for. … You will continue to see pends if you do not register and map the lab as well… There are 79 tests that require Advance Notification. …Just because you are not performing a Decision Support Test does not mean you don’t have to comply with the program. All of this information is listed in our Administrative Protocol… The Beacon team advised that this is the same for the PCTC lab. You will continue to see these pends if you do not register and map your lab [to the BeaconLBS system]…”

Contact J. Michael Luton at 772-567-6340 ext 108, or jmluton@primarydocs.net.


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