CAP asks UHC to forgo Designated Diagnostic Provider program

February 2, 2022

The College of American Pathologists (CAP) has joined six other provider advocacy groups in formally requesting UnitedHealthcare (UHC) forgo its Designated Diagnostic Provider (DDP) program that was introduced last year in an attempt to further tighten the payer’s network and direct patients to preferred laboratories.

Originally set to be instituted July 1, 2021, UnitedHealthcare proposed to only covers outpatient diagnostic lab services for commercial members when performed by a DDP, a new quality status the insurer is asking labs to meet in an effort to tighten its network. Per UHC, to participate, in-network hospital-affiliated and independent labs must meet certain quality and efficiency criteria and complete an associated survey.

However, concerns expressed by CAP and the American Hospital Association over the patient confusion that could be created by having in-network labs that did not gain DDP status led UHC to delay full implementation of the program until January 2022. The program was also revised to allow in-network labs to receive a tiered payment status based on whether or not they’ve received DDP status. A provider that is not a Designated Diagnostic Provider will be paid at the lowest tier/higher cost share according to the patient’s plan, according to UHC.

Previously, in-network labs who did not receive designated provider status would see their outpatient diagnostic lab services denied as non-covered. Non-participating labs are prevented from applying for designated provider status.

In a January 26 letter, CAP, along with the American Medical Association, the American Academy of Dermatology, the American College of Obstetrics and Gynecology, the American College of Rheumatology, American Society of Dermatopathology, and the Medical Group Management Association asked UnitedHealthcare to seek additional stakeholder input or permanently cease implementation of the program altogether.

“While we welcome UHC’s efforts to revise DDP from its original ‘in-or-out’ design to a tiered-based model, we remain concerned that the January 2022 rollout will harm smaller independent pathology groups, putting them at a disadvantage by being unable to qualify for DDP designation,” the letter states. “This unintended consequence will create a ripple effect by causing disruption in longstanding professional referral relationships between treating physicians and their trusted and
preferred pathologists.”

As a reminder, DDP status will not affect lab services rendered as part of inpatient admissions, emergency room visits or outpatient surgery pre-operation testing when billed as part of a global surgical package, according to UHC.

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