Becker's Hospital Review

18 CFO / FINANCE New UnitedHealthcare policies change coverage for lab tests, specialty drugs; hospitals want CMS to review them By Morgan Haefner T he American Hospital Association urged CMS to review policy changes from UnitedHealthcare for diagnostic and specialty pharmacy services that the insur- er says are needed to lower medical costs. In a Feb. 4 letter to acting CMS Administra- tor Elizabeth Richter, the AHA argued two new UnitedHealthcare policies "create signif- icant barriers to access to necessary diagnos- tic and specialty pharmacy services for tens of millions of health plan enrollees." One policy is UnitedHealthcare's designat- ed diagnostic provider program. Beginning July 1, diagnostic tests completed at a facility that isn't a "designated diagnostic provid- er" 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 nondesignated lab, but otherwise, members will need to pay out of pocket for testing that is completed at a nondesignated lab. e requirement doesn't include inpa- tient or emergency room tests. e AHA said this setup could result in sur- prise 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 con- tacting members who have used a non-des- ignated diagnostic provider in the past to help them better understand the new policy, a spokesperson from the insurer said. e change aims to address discrepancies in how much certain diagnostic tests cost in a hos- pital 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 ser- vices 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 cri- teria include getting accreditation from or- ganizations like the American Association for Laboratory Accreditation, the College of American Pathologists and e Joint Com- mission. Providers who meet the criteria af- ter the deadline will continue to be reviewed for designated diagnostic provider status. Fa- cilities 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 United- Healthcare, the insurer said. e other policy AHA mentioned in its letter concerns specialty pharmacy coverage. e AHA said UnitedHealth is "driving a signifi- cant change in the drug supply chain through its OptumRx subsidiary." New specialty phar- macy policies in plans are increasingly requir- ing providers to accept drugs purchased and handled by OptumRx, according to the AHA. In a statement about the changes, United- Healthcare said: "As of Oct. 1, 2020, outpa- tient hospital providers in UnitedHealthcare's commercial network are required to source certain specialty drugs from indicated special- ty pharmacies, unless otherwise authorized by UnitedHealthcare. is approach allows UnitedHealthcare to potentially eliminate un- necessary costs from the healthcare system to help make healthcare more affordable." e two policies "warrant immediate atten- tion 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. n Intermountain health plan CEO resigns By Morgan Haefner M ike Cotton, the president and CEO of Intermountain Healthcare's health plan SelectHealth, resigned, the Salt Lake City-based health system said. Mr. Cotton resigned from his role Jan. 25 because of family reasons. He is re- locating to Atlanta to care for his family there, Intermountain said. "Mike and I have discussed various options to support him through this, such as working from Georgia, but he is clear that he needs to be fully focused on family rather than dividing his time," Marc Harrison, MD, president and CEO of Intermountain, said in a news release. "Family health and values are founda- tional to Intermountain, just as they are to Mike and his family, and we under- stand and fully support his decision." Bob White, SelectHealth's COO, will serve as interim president and CEO while Intermountain searches for a successor. Mr. Cotton joined SelectHealth in 2020. SelectHealth offers health insurance in Utah, Idaho and Nevada. n

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