New UnitedHealthcare policies change coverage for lab tests, specialty drugs. Hospitals want CMS to review them

The American Hospital Association urged CMS to review new policy changes from UnitedHealthcare for diagnostic and specialty pharmacy services that the insurer says are needed to lower medical costs.

In a Feb. 4 letter to acting CMS Administrator Elizabeth Richter, the AHA argued two new UnitedHealthcare policies "create significant barriers to access to necessary diagnostic and specialty pharmacy services for tens of millions of health plan enrollees." 

One policy is UnitedHealthcare's designated diagnostic provider program. Beginning July 1, diagnostic tests completed at a facility that isn't a "designated diagnostic provider" won't be covered for UnitedHealthcare's commercial health plan members. Labs that are designated diagnostic providers will be reimbursed at a fixed rate. 

Under the policy, coverage will be denied for patients who receive testing at a non-designated laboratory even if the provider is considered "in-network." UnitedHealthcare is providing members a one-time exemption if they use a non-designated lab, but otherwise, members will need to pay out of pocket for testing that is completed at a non-designated lab. The requirement doesn't include inpatient or emergency room tests.

The AHA said this setup could result in surprise medical bills for patients, adding that the policy attempts to "redefine the concept of an 'in-network' provider and limit patient access to a much smaller pool of laboratory service providers."

UnitedHealthcare is updating its provider directories to show the change and is contacting members who have used a non-designated diagnostic provider in the past to help them better understand the new policy, a spokesperson from the insurer said. The change aims to address discrepancies in how much certain diagnostic tests cost in a hospital outpatient setting versus a freestanding laboratory, according to UnitedHealthcare.

"UnitedHealthcare members may pay as much as 500 percent more on average for lab services, depending on where they are performed. Designated Diagnostic Provider benefit designs will cover outpatient lab services provided by qualified free-standing and outpatient hospital laboratories who meet quality and efficiency criteria," the insurer said in a statement.

Providers have until Feb. 28 to meet certain quality and efficiency metrics to become a designated diagnostic provider. Some criteria include getting accreditation from organizations like the American Association for Laboratory Accreditation, the College of American Pathologists and the Joint Commission. Providers who meet the criteria after the deadline will continue to be reviewed for designated diagnostic provider status. Facilities that don't meet the requirement will still maintain their network status, which is where AHA says the confusion lies.

"Because the enrollees' plan materials still will identify these non-designated labs as 'in-network' providers, this policy will create significant confusion for those seeking care," the AHA said.

Members who are not aware of the change and face a bill can file an appeal with UnitedHealthcare, the insurer said.

The other policy AHA mentioned in its letter concerns specialty pharmacy coverage. The AHA said UnitedHealth is "driving a significant change in the drug supply chain through its OptumRx subsidiary." New specialty pharmacy policies in plans are increasingly requiring providers to accept drugs purchased and handled by OptumRx, according to the AHA.

In a statement about the changes, UnitedHealthcare said: "As of Oct. 1, 2020, outpatient hospital providers in UnitedHealthcare's commercial network are required to source certain specialty drugs from indicated specialty pharmacies, unless otherwise authorized by UnitedHealthcare. This approach allows UnitedHealthcare to potentially eliminate unnecessary costs from the healthcare system to help make healthcare more affordable."

The two policies "warrant immediate attention by [CMS] in its oversight of health plans serving enrollees in Medicare Advantage, Medicaid managed care, Children's Health Insurance Program and Health Insurance Marketplace health plans," the AHA said.

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