UHC to require Designated Diagnostic Provider status for non-patient payments

February 10, 2021

By: Alex Mitchell, Quality Programs Coordinator

Update: Following a meeting with College of American Pathologists reps, UHC announced it was delaying the deadline for labs to complete the quality survey to March 10. The payer has since removed the deadline to complete the survey entirely.

Beginning July 1, 2021, UnitedHealthcare will only cover outpatient diagnostic lab services for commercial members when performed by a Designated Diagnostic Provider, 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 the associated survey.

  • Complete the Designated Diagnostic Provider lab quality questionnaire
  • If you meet the lab quality and efficiency requirements, you will become a Designated Diagnostic Provider for lab services and be notified accordingly
  • If you do not meet the lab Designated Diagnostic Provider requirements for lab services, a dedicated network representative will reach out to follow up and support the process

Labs who do not receive designated provider status will remain in-network with UHC, however, outpatient diagnostic lab services will deny as non-covered. Non-participating labs are prevented from applying for designated provider status.

The Designated Diagnostic Provider 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.

The following are the places of service with ancillary agreements we’ve confirmed will be impacted:

  • 19 (Off-campus outpatient hospital)
  • 22 (On-campus hospital outpatient)
  • 81 (lab)

Those with medical group agreements, meanwhile, will only be in-scope of the policy if billing POS 81. Groups unsure of their agreement type should contact UHC.

In 2022, UHC said it intends to extend this program to major radiology services (MR, CT, PET/Nuclear Medicine).

“We are continuing our work toward the Triple Aim of better care, better health and lower costs for UnitedHealthcare members,” UHC said in a statement on its website. “Designated Diagnostic Provider benefit designs are intended to maximize member benefits for lab services and ensure laboratory services are performed by providers that meets both efficiency and quality requirements.” 

However, the American Hospital Association recently expressed displeasure with UHC’s practices in a letter to CMS.

In the letter, pointed out that UHC could be attempting to game the system by redefining what in-network means. “If a patient obtains care at a non-designated laboratory – even those supposedly “in-network” – coverage for their services will be denied, and the patient will be responsible for payment in full,” AHA said in its Feb. 4 letter. “In short, the DDP program is attempting to redefine the concept of an “in-network” provider and limit patient access to a much smaller pool of laboratory service providers.”

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