The CAP continues to express concerns with UnitedHealthcare on their Designated Diagnostic Provider laboratory program. In an April 20 letter, the CAP urged UnitedHealthcare to immediately and permanently cease implementation of this program because of the burden and confusion created for pathologists and their patients, the lack of transparency, and – most importantly – the potential financial harm for UnitedHealthcare plan members. The CAP works with the private-sector insurers, like UnitedHealthcare, to ensure access to pathology and laboratory services across all settings.

The Designated Diagnostic Provider program requires laboratories to meet UnitedHealthcare-determined efficiency and quality requirements to become a Designated Diagnostic Provider. However, laboratories that do not meet these requirements will still be in-network, “but UnitedHealthcare will not cover and will deny payment for outpatient diagnostic laboratory services provided by these facilities, leaving patients likely ‘liable for charges.’” The CAP told UnitedHealthcare that it would potentially subject patients to the full payment for services received at in-network but non-DDP facilities and is counter to efforts to protect patients and eliminate surprise medical bills.

“Even those patients who are diligent about seeking care from in-network facilities may find themselves with unanticipated bills,” the CAP letter states. “Similar confusion can be expected from ordering providers when making referrals. This is the essence of our concern: the proposed program sets up a needlessly confusing situation by having providers who are nominally in your network (as explained to us) whose services will not be covered, which will (legitimately) be perceived as predisposing to the issuance of ‘surprise bills’ to patients.”

The CAP also reiterated concern with the additional requirements put forward by UnitedHealthcare in their Laboratory Test Registry Protocol, saying it would take significant time, resources, and education to implement, on top of the efficient and adequate CPT coding currently in use. The CAP strongly supports the continued use of the CPT code set as it is developed with broad stakeholder input and provides a uniform language that accurately describes medical, surgical, and diagnostic services provided by physicians and other qualified health care professionals.

UnitedHealthcare had announced the new Designated Diagnostic Provider program impacting outpatient laboratory services for fully insured commercial members. Effective July 1, 2021, the insurer will only cover outpatient laboratory services for members when delivered by a “Designated Diagnostic Provider” laboratory. Laboratories that are not a “Designated Diagnostic Provider” will remain in-network, but outpatient diagnostic laboratory services will be denied as non-covered. UnitedHealthcare sent communications to all diagnostic providers to encourage them to become a Designated Diagnostic Provider by completing a quality questionnaire.

Visit the CAP’s private sector advocacy webpage for more information.