New United Laboratory Policy Puts Profits ahead of Patient Care

The availability of swift, accurate and reliable diagnostic testing during the public health emergency has been extremely important. Lab testing is essential to proper treatment, enabling clinicians to diagnose and treat a vast spectrum of issues. And, curtailing the ability of providers to offer onsite diagnostics can severely limit patient access to care, as the New York Times reported recently.

We know that labs play a vital role in health care, which makes a recent decision by UnitedHealthcare to drastically reduce patient access to lab services all the more alarming. In January, United announced its Designated Diagnostic Provider (DDP) program for fully-insured plans, which will eliminate coverage for diagnostic tests at all freestanding and hospital labs – including those in its network – unless the facilities are an established ”Designated Diagnostic Provider.” In order to become designated, freestanding and network labs must meet a United-determined threshold for quality and agree to accept “efficiency criteria.” This new criteria means significant reductions in reimbursement that most hospital labs will be unable to sustain if they are to maintain their current services and standard of quality. Unlike many freestanding labs, hospital-based labs must be able to satisfactorily process a wide-array of complex tests to meet the needs of the hospital’s clinicians, making their testing capabilities often more advanced.

As a result, fewer – if any – hospital-based labs will remain available to United enrollees. This will significantly reduce patient access to care and choice of provider, with United subjecting patients to a higher risk of an unanticipated medical bill.

Reduction in Patient Access

In order to provide acceptable coverage, health plans are expected to contract with an adequate number of care providers to meet the needs of their enrollees. This allows patients to have confidence that they can easily find a network provider to render necessary care covered by their plan. This is of such importance that federal regulators identified network adequacy as a core consumer protection when establishing the federal Health Insurance Marketplaces under the Affordable Care Act.

The DDP program undermines this concept by attempting to redefine “in-network.” Under the program, if patients obtain care at a non-designated laboratory – even those supposedly “in-network” – coverage for these services will be denied, and United will cause the patient to be responsible for payment in full.

Elimination of Potential Preferred Care

The DDP program prevents patients from selecting the lab-based care that best suits their needs. Although United presents the testing offered at their low-cost labs to be interchangeable with hospital-based labs, the two in fact have significant differences. For example, hospital labs are traditionally open around the clock, while reference and independent laboratories may only offer times during traditional working hours. Hospital labs also have a stronger connection with physicians and work alongside clinicians in the health care workforce to meet the needs of patients.

Further, effective patient care relies on lab services that offer quality, easy access and quick reporting, all of which are more likely at a hospital-based, clinical laboratory. The business model for independent and reference laboratories is based on increasing volume of total tests performed. This can come at the expense of spending the time to ensure high quality and accuracy.

United’s Surprise Changes Could Mean More Surprise Bills

The DDP program increases the risk that patients will receive unanticipated medical bills for care they believed to be covered by their insurance. Patients are most likely to seek medical care from in-network providers based on an understanding that care from such providers will be covered by their plan. Indeed, many consumers evaluate plan options based on the provider network that would be available to them. In fact, United encourages this practice.

This program, however, distorts this concept. If a prudent United enrollee – or the individual’s provider ordering the test – elects an “in-network” but non-designated lab, coverage for services would be denied and the patient is responsible for payment of these services. And, because United is implementing this policy in the middle of a coverage year, patients may have selected the in-network lab before the program was introduced, only to have their coverage status change mid-year. This confusing, unprecedented definition of “in-network” will inevitably result in surprise medical bills for care patients rightly expected to be covered. Notably, because United claims that these providers remain “in-network, recent patient protections against surprise medical bills would be undermined by United and would not apply.

United is limiting access to care and setting patients up to unknowingly be on the hook for unexpected medical expenses they were told would be covered when they purchased their coverage. This will harm patients financially and have a chilling effect on their willingness to participate in their care planning.

The health care system has been moving toward giving patients a more active role in their care. Unfortunately, United’s prioritization of profits over patients runs amok of this concept.

Terrence Cunningham is the AHA’s director of administrative simplification policy.