UnitedHealth Sets More Billing Rules for Labs, Pathologists

UHC seeks refunds for some prostate biopsies and requires member consent for out-of-network referrals

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SUBMITTING CLINICAL LABORATORY AND PATHOLOGY TEST CLAIMS to UnitedHealthcare (UHC) will be more complex after the nation’s largest health insurer announced three significant changes in its claims processing procedures.

The three changes involve:

• Requests for refunds from anatomic pathology (AP) groups that UHC says may have submitted incorrect claims for biopsies,

• Rules for out-of-network referrals, and

• More tests needing prior approval.

This first change could be the most troubling of the new rules. Anatomic pathology (AP) groups may need to pay refunds on prostate biopsy cases billed for members in UHC’s Medicare Advantage plans with the CPT code 88305 (level IV surgical pathology,gross and microscopic examination) instead of HCPCS code G0416, said LeighPolk, PathLab Marketing Specialist at Change Healthcare.

Out-of-Network Consent

The second change was made this summer, when UHC instituted a new rule requiring clinical laboratories, AP groups, and other providers to get UHC’s members to signconsent forms for out-of-network referrals. The third change came when UHC added more codes to the list of services requiring prior authorization. Each of the new changes is discussed below.

On top of these challenges, clinical laboratories and AP groups must understand and comply with UHC’s new Laboratory Test Registry Protocol that goes into effect on Jan. 1, 2021 (see TDR, Aug. 3, 2020). UHC’s new policy for CPT code 88305 affects the most common of all billing codes in anatomic pathology.

“It’s been UHC policy since 2015 to align its policies with guidance from the federal Centers for Medicare and Medicaid Services,” said Polk. “Under this guidance, prostate biopsy claims must be submitted with HCPCS code G0416 with one unit. k88305 versus G0416.

“However, UHC’s Medicare Advantage plans have not denied cases sent with 88305 versus G0416,” she advised. “When coding, AP groups may not be aware of the payer associated with the case. “For our client AP groups, Change Healthcare implemented processes that identify all prostate biopsy cases for UHC’s Medicare Advantage members,” said Polk. “These cases are converted from 88305 to G0416 before Change Healthcare submits those claims to UHC.”

AP groups that use other billing companies may want to determine if those billers are using the proper code when billing for CPT 88305, Polk recommended.

On July 1, UHC began requiring clinical labs, AP groups, and all other providers serving members in commercial plans to sign consent forms for out-of-network referrals for non-emergency care. “UHC said labs and anatomic pathologists can have UHC members in commercial plans sign a ‘Member Consent for Referring Out-of-Network Form,’” explained Polk. “The form tells UHC members that they may have to pay more out-of-pocket or the entire cost of the out-of-network care depending on each member’s out-of-network benefits. As an alternative, UHC said providers can get prior approval for the out-of-network referral by calling the phone number on the back of the UHC member’s healthcare identification card.

“If a lab is out-of-network, it can get a UHC member’s consent by downloading the ‘non-preferred’ laboratory consent form at UHCprovider.com,” she added. “Once the member signs the form, the provider can upload the signed form to UHC. It might, however, be difficult or impossible for labs to know if a UHC member is in a commercial plan without seeing the patient’s insurance card.

Could Face Penalties

“While UHC is not saying they’ll deny out-of-network claims if there’s no signed consent form, they are saying that the out-of-network provider could face penalties,” commented Polk.

On its member-consent form, UHC explained that out-of-network care means the patient may pay more out of pocket, even if the member has out-of-network benefits, or may need to pay for the full cost for the referred service if the member lacks out-of-network benefits.

The UnitedHealthcare form also requires providers to explain to patients why they are being referred for out-of-network care and to disclose any financial interest the provider may have in the out-of-network care provider.

“If, upon seeing this information, you’re okay with your doctor’s choice to involve an out-of-network healthcare provider in your care, please give your consent below,” the form states. “This consent will only be valid for the service(s) your doctor refers on the date you sign this consent.”

UHC Adds Lab Tests Needing Prior Approval

PRIOR APPROVAL IS NOW REQUIRED for some 40 new CPT codes that clinical laboratories and anatomic pathology groups would use when billing UnitedHealthcare (UHC). If clinical labs and AP groupsdo not get prior approval for these new codes, the health insurer will not pay for these tests or procedures, noted LeighPolk, PathLab Marketing Specialist at Change Healthcare.

The new codes include those for proprietary laboratory analyses (PLA) test codes between 0172U and 0201U, and for the following CPT codes: 87480, 87481, 87482, 87510, 87511, 87512, 87623, 87660, 87661, 87797, 87798, 87799, 87800, 87801, Change Healthcare reported.

“Although pathologists and clinical labs have 90 days from the date of service to receive prior authorization, labs and AP groups should keep in mind that claims submitted without prior authorization will be denied and cannot be resubmitted,” warned Polk.

Diana Richard, Director of the Anatomic Pathology Program at XIFIN, recommended that AP groups appeal these denials if the prior authorization can be acquired, even if the group is unlikelyto get paid. “If the services rendered were medically necessary, and the prior authorization was acquired within 90 days of the date of service, pathology groups need to express to the payer, through this formal process, that they should be paid for the work completed,” she asserted.

“When future discussions happen with the payer, these ‘push-back’ events provide AP groups with the critical documentation they will need to support justification for change.”

Contact Leigh Polk at 800-832-5270 x2941 or Leigh.Polk@changehealthcare.com; Diana Richard at 843-319-2409 or drichard@xifin.com.

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