In our first “guest reporter” series, Brian Crowley, CEO of Integra Enterprises and someone who has worked closely with FADAA and FARR to drive the urinalysis screening segment of the industry towards ethical behavior and evidence-based use, writes below about UnitedHealthcare and the posture they have been taking relating to authorizations for the growing popularity of genetic testing.
In all fairness to Brian, he sent us this information all the way back on April 1, 2016, well before United filed suit (last week) against Sky Toxicology and others in federal court….
UnitedHealthcare recently warned out-of-net- work laboratories not to waive or cap patients’ copayments or deductibles. In the same bulletin, it also announced that it will require prior authorization for all genetic tests later this year. This follows a somewhat similar approach by Cigna, who sued Skytox Labs in a West Palm Beach, FL court for failing to collect patient copayments or deductibles.
In a bulletin to providers March 1, UHC says: “Effective Q3 2016, UnitedHealthcare will require care providers to obtain prior authorization for genetic testing for our commercial members. Details on how to request prior authorization, the genetic testing policy to be used in the review process, and other information will be included in a future Network Bulletin newsletter and on our physician portal.”
On the issue of waiving patients’ fees, UHC is specific and threatening. “Some nonparticipating labs attempt to attract customers by waiving or capping copayments, coinsurance or deductibles. Such arrangements undermine the benefit plan by eliminating incentives created to encourage members to choose to receive care within the network and to discourage over-utilization of services,” says UHC, the nation’s largest health insurer.
This is a similar approach that what other payers have taken against testing in general.
Many payers contracted with the Lab Corp subsidiary Beacon LBS (Lab Benefit Solutions), which now requires providers and labs to prove that tests meet medical necessity prior to ordering and authorization. Having demo’d this application, I can say that the tool very much seems to be engineered in favor of payers and its strategic partner Lab Corp, as a means to monopolize the testing market, under the guise of improving patient care. Nothing user friendly or streamlined about it.
If this is what the future looks like for out of network independent labs and provider owned labs? Then its game over!
The trend seems to be heading toward an in network, bundled rate for treatment services. Being involved in the behavioral health market, I see this kind of approach having huge repercussions for providers. If the industry as a collective group doesn’t proactively engage now in the debate with payers now about what guidelines make sound medical and clinical sense for treatment and drug testing, we have some serious problems.
This is the absolute first step as payers seems to be in an all-out “overcorrection war” with drug treatment providers about over-utilization and abuses with drug testing. This is especially apparent in Florida currently, given the number of providers abuses in the last three years. Until this issue is cleared up and mutually agreed upon protocols are in place, providers will continue to be bombarded by payers for all services and reimbursements.
Providers must be able to show effective treatment outcomes and drug testing plays a pivotal role in this. However, the larger problem for the behavioral health and substance abuse industry is that it can’t seem to unite and collaborate enough, to result in a meeting of the minds with payers about proper medical necessity guidelines for substance abuse disorders and drug testing.
Payers like UHC are now looking heavily at the ways providers have dropped the ball when it comes to drug testing and are feverishly denying or delaying all reimbursement claims as a result.
“UnitedHealthcare’s benefit contracts exclude coverage for any out-of-network lab services for which the provider waives the coinsurance, copayments, or deductibles. In addition, routine waiver of coinsurance, copayments, or deductibles may be a violation of the federal False Claims Act, subject to investigation by the Office of the Inspector General and/or any applicable state insurance department’s fraud division,” wrote UHC.
The bulletin also explains that UHC’s network includes “more than 1,500 clinical reference laboratories.” In-network physicians and other providers “are expected to refer our members to network laboratories for clinical lab and anatomic pathology, unless otherwise authorized by UnitedHealthcare consistent with their participation agreement,” the bulletin says.
The warning about waiving patients’ payments is likely a result of leaving so many laboratories out of its network, stated Linda D. Liston, CPC, Director of Managed Care Services for McKesson Business Performance Services.
“UnitedHealthcare gets a lot of out-of-network charges because it won’t give small, local, or regional labs contracts. We know this from our experience with UHC,” she explained.
“When we tell UHC that it is receiving a large number of lab test claims for UHC members in a particular area and that is a reason why it should contract with those local or regional labs, its officials say, ‘We’ve got our national agreement and don’t need another lab or pathology group,” explained Liston, who has served as McKesson’s director of managed care services for 20 years.
Providers need to start taking collective responsibility for their future with payers, or payers are simply going to continue to dictate what they determine what is or isn’t necessary in treatment. Its time to stop moaning about the problem and become part of the solution, by organizing and mobilizing a force for change in the substance abuse treatment community. Instead of more talking, we need more doing. Together is where the power is. As William Wallace said in Braveheart “If we could just unite the clans, we can win” – but therein lies behavioral healths greatest problem, lack of unity, within its own ranks.
If only it could rise above its petty differences and have the courage to call out the offenders among its ranks and focus on the real threat, the payers who just see a fragmented industry with little real leadership.
Are there any real leaders out there in behavioral health who can rally the troops and are they any troops out there humble enough to follow and wise enough to put their hand in their pockets and pay for such an effort?
Time will tell. Time will tell.
From the author: “Parts of this article are taken from an excerpt from an article in the March 21 issue of THE DARK REPORT. UHC’s battle against out-of-network labs, as well as its plans to begin requiring pre-authorization for genetic testing, are included in the original article, available to paid members.”
NOTE: SoberLawNews.com and its owners, editors, and writers have republished this writing from Mr. Crowley for informational purposes only and do not attest to the veracity of the comments made herein (though we tend to agree with what is being said). For further information, please contact Mr. Crowley directly, email@example.com