Managed Care Update

In Florida, More Tests Added to UHC’s Decision-Support Program

IN THE FIRST BROAD EXPANSION OF ITS pilot decision-support program for clinical lab testing in Florida, UnitedHealthcare (UHC) will add genetic and molecular tests, drug tests, and pathology procedures, among other assays starting in two months.

On March 1, UHC will expand its laboratory benefit management program in Florida beyond the initial 80 routine anatomical and clinical pathology tests. To be added are 40 genetic and molecular diagnostic assays, some name-brand tests, and broad categories of testing such as drug tests and pathology procedures, according to a one-page summary in UnitedHealthcare’s December network bulletin report to providers.

In April 2015, UHC and Beacon Laboratory Benefit Solutions, a division of Laboratory Corporation of America, started the lab benefit program in Florida for its fully-insured commercial members in the Sunshine State. (See TDR, March 9, 2015.)

In its latest announcement, UHC said it aims, “to improve the care provider experience,” by revising the list of tests that require physicians to use the BeaconLBS decision support system. Also, UHC will make, “Accommodations for CLIA and referring physician claim submission requirements for physician offices.” In addition, UHC and BeaconLBS will add “new decision support features,” additional integration between electronic health record and laboratory ordering systems, and improve the design of the “physician decision support platform.”

An email inquiry from THE DARK REPORT seeking more information from UHC was not returned by press time.

CPT Codes Not Identified

“It’s interesting to note that UHC is not specific regarding which CPT codes will be involved,” said one lab director who saw the announcement. “All we know is there are broadly-listed test categories.

“With a projected start date of March 1, it may be that the lack of specificity is designed to alleviate an onslaught of torches and pitchforks from specialty labs seeking to appeal for removal from the projected test listing,” the lab director added. “It’s likely that the CPT codes will be revealed sometime in late February.”

In its announcement, UHC said it was making the changes based on feedback from care providers and evaluation of pilot results. UHC has referred to the initiative in Florida as a pilot program since it was started in 2015.

Note that some of the tests being added are specific brand-name tests (such as MammaPrint assay from Agendia) and others are general categories of testing such as “drug testing: presumptive and definitive.” It is likely that these broad categories of testing will generate the most controversy among clinical lab directors and pathologists.

For example, one category of testing being added on March 1 is “Pathology—dermatopathology, hematopathology, all other.” This category is so broad it appears to encompass all work by all pathologists. Another broad category is “drug testing: presumptive and definitive.” Adding “drug testing” in this way suggests that UHC is seeking a way to manage the rapid rise of drug testing nationwide. In addition, United-Healthcare may also be seeking a way to manage the fraud that often occurs in the drug testing segment of the clinical laboratory industry.

Note that hereditary breast and ovarian cancer testing (BRCA1/2) require prior authorization, UHC said.

UHC Publishes First List of Tests for LBMP

HERE’S A LIST OF THE TESTS AND broad categories of laboratory tests that UnitedHealthcare is adding to its decision support program in Florida. This list of tests is available on the UHC website.

  • Ashkenazi Jewish carrier screening
  • Breast cancer index
  • Chlamydia trachomatis/Neisseria gonorrhoeae with or without Trichomonas vaginalis, NAT
  • Chromosome SNP microarray panel
  • Cystic fibrosis carrier screening and sequencing
  • Cytology (non-gynecology)
  • Drug testing: presumptive and definitive
  • EndoPredict breast cancer test
  • Expanded carrier screening
  • Gene expression profile tests for evaluation or management of multiple myeloma
  • Gene expression profiling as a technique for colorectal cancer (CRC) risk assessment or management
  • Gene expression profiling as a technique of managing the treatment of breast cancer
  • Gene expression profiling of cutaneous melanoma
  • Gene expression profiling to identify the tissue of origin for cancers of unknown primary site
  • Gene-based tests for the screening, detection and management of prostate cancer
  • HCV, quantitative, NAT
  • Hereditary breast and ovarian cancer testing (BRCA1/2)
  • Herpes simplex virus (HSV) antibodies
  • HIV-1, quantitative, RNA
  • HPV, high-risk (HR) detection
  • Leukemia/lymphoma immunopheno-typing profile (by flow cytometry)
  • MammaPrint breast cancer recurrence assay
  • Molecular pathology procedures
  • Multi-gene hereditary cancer panels
  • Multi-gene pharmacogenetic testing
  • Multi-gene tumor panels to guide cancer treatment
  • Non-invasive prenatal screening (NIPS/NIPT)
  • Oncotype DX Breast Cancer Test • Pathology, Dermatopathology,Hemato-pathology, all other
  • Prosiga Breast Cancer Assay
  • Prostate Specific Antigen (PSA) Assay
  • Thyroid panel
  • Thyroxine (T4), free
  • Triiodothyronine (T3), free testosterone
  • Topographic genotyping
  • UroVysion
  • Vitamin B12
  • Vitamin D, 25-hydroxy
  • Whole exome sequencing
  • Whole genome sequencing

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