UnitedHealthcare Warns Labs Not to Waive Patient Fees
Insurer says routinely waiving such fees may violate federal law, lead to state fraud inquests
By Joseph Burns | From the Volume XXIII No. 4 – March 21, 2016 Issue
UPMC-KingMed Digital Pathology Venture Improves Patient CareFDA Steps Up Test Enforcement, Saying Tests Need Clearance
CEO SUMMARY: UnitedHealthcare directly tackled the issue of out-of-network labs waiving or capping copayments, coinsurance and deductibles that are to be paid by patients. In a network bulletin this month, UHC said that such arrangements may violate federal law and could lead to state insurance department investigations into false claims. In the same bulletin to physicians and other providers, UnitedHealthcare also said it would require prior authorization for all genetic tests beginning later this year.
IN ITS LATEST NETWORK BULLETIN, UnitedHealthcare 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.
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 overutilization of services,” says UHC, the nation’s largest health insurer.
“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.
referrals To Network Labs
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.
UnitedHealthcare officials did not respond to a request for comment.
Insurer says routinely waiving such fees may violate federal law, lead to state fraud inquests
By Joseph Burns | From the Volume XXIII No. 4 – March 21, 2016 Issue
UPMC-KingMed Digital Pathology Venture Improves Patient CareFDA Steps Up Test Enforcement, Saying Tests Need Clearance
CEO SUMMARY: UnitedHealthcare directly tackled the issue of out-of-network labs waiving or capping copayments, coinsurance and deductibles that are to be paid by patients. In a network bulletin this month, UHC said that such arrangements may violate federal law and could lead to state insurance department investigations into false claims. In the same bulletin to physicians and other providers, UnitedHealthcare also said it would require prior authorization for all genetic tests beginning later this year.
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 overutilization of services,” says UHC, the nation’s largest health insurer.
“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.
referrals To Network Labs
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.
UnitedHealthcare officials did not respond to a request for comment.