IN FLORIDA, BOTH CLINICAL LABS and physicians have expressed concerns UnitedHealthcare’s Laboratory presented in full on this page and the following page. about Benefit Management Program that formally becomes effective on October 1. From that date forward, physicians will be required to obtain advance notification or pre-authorization for 81 tests.
Following our request for comment from UnitedHealthcare, BeaconLBS, and Laboratory Corporation of America (owner of BeaconLBS), THE DARK REPORT was asked to submit questions in writing. Upon receipt of those questions, statements were provided by UnitedHealthcare of Florida and BeaconLBS. Each statement is Information about the Laboratory Benefit Management Program is available on the UnitedHealthcare website. There are documents that describe the process of advance notification which is described as follows:
Advance notification is required for Decision Support Tests rendered in the office (place of service 11) or clinical laboratory (place of service 81). If advance notification is not confirmed for Decision Support Tests, the test will not be eligible for payment. [Underline by TDR.]
From UnitedHealthcare of Florida
Provided by a company spokesperson:
Below, are some additional facts to help you better understand our pilot [of the Laboratory BenefitManagement Program] and its goals:
- UnitedHealthcare has a national clinical laboratory agreement with Labcorp.
- The lab program does NOT require prior authorization on tests ordered with the exception of the BRCA, which is a genetic test for breast cancer. However, it does request advance notification for several other tests. It is important to note that the advance notification process is NOT a clinical coverage review. It helps us verify necessary benefits and share applicable evidence-based clinical guidelines with the treating physician.
- UHC network laboratories are not required to participate in the BeaconLBS Laboratory of Choice network. However, network laboratories are required to comply with UHC Administrative Protocols and Clinical Policies. So, registration is required to ensure that the laboratory can meet those program requirements and minimize claims impact.
- To become a Laboratory of Choice, the lab does not need to pay a fee. However, the lab must meet (or negotiate) the terms of the BeaconLBS agreement, which include efficiency and quality criteria. For additional information, please visit: https://www.united- healthcareonline.com/b2c/CmaAction.do?channelId=9cc7b96891e22410VgnVCM2000002a4ab10a (or http://tinyurl.com/p633fm8)
This protocol is a notification requirement, not a precertification, prior authorization, or medical necessity determination. The participating physician (ordering provider) must notify UnitedHealthcare using Physician Decision Support prior to ordering the service.
The rendering laboratory will receive advance notification confirmation in the Outcome Summary or at BeaconLBS.com. The Outcome Summary is a printable onscreen message that includes test ordering results…
Of interest to pathologists and lab managers is the requirement that, when the physician is ordering tests covered by UnitedHealth’s decision support requirement to obtain advance notification, two elements must be validated, as noted on the UnitedHealthcare website. First, the ordering provider must complete an electronic “question and answer (Q&A) through Physician Decision Support.” Second, the rendering provider must meet the requirements of “CAP accreditation, sub-specialty certification, and/or secondary pathology review” as mandated by the program.
No Balance Bill To Members
In another section on the website, UnitedHealthcare writes that, for the rendering laboratory, “If there is no advance notification on file and the services are performed in place of service (POS) 11 or 81, the claim will deny as provider liability. Network providers cannot balance bill the member for covered services.”
As these extracts from the information available on the UnitedHealthcare website indicate, the Laboratory Benefit Management Program has much complexity for physicians at the time they want to order tests and for each laboratory provider listed as a “Laboratory of Choice” for this program.
Provided by a company spokesperson:
Beacon Laboratory Benefit Solutions (BeaconLBS) identifies for physicians and their patients, high-quality, accredited laboratories and uses evidence-based clinical guidelines to improve quality and appropriate utilization of laboratory services. By making it easier to share information between physicians, labs, and health plans, BeaconLBS is helping lower the cost of care while improving the coordination and quality of a patient’s laboratory services.
Lab testing is critical to patient care. As medical technology advances and becomes more complex, physicians are looking for education and support when ordering certain tests—par- ticularly esoteric and genetic tests—and in efficiently identifying in-network labs for their patients’ testing. Health plans are seeking better and easier ways to support patient care and physician choice while managing lab utilization and costs.
BeaconLBS is a laboratory benefit solutions company that connects physicians, payers and labs. It includes an online physician decision support and test ordering system that helps physicians choose the right tests, select labs that meet quality and efficiency criteria, and lower out-of-pocket costs for patients by meeting health plans’ coverage requirements.
BeaconLBS will not direct the referral of specimens to labs. Physicians will select the referral lab for testing they order as they do today. The network will include independent labs, hospital labs, and pathology labs that meet the established quality and efficiency criteria.