Jun 1, 2010 | Laboratory Management and Operations, Laboratory Pathology, Managed Care Contracts & Payer Reimbursement
Doctors Opt For More Resources, Fewer Administrative Burdens Over Independence
There’s an interesting trend which has significant implications for pathologists and the clinical laboratory testing industry over the long term. For a variety of reasons, growing numbers of physicians are selling their medical practices to hospitals and health systems. This is creating a noticeable reduction in the number of private practices in the United States.
As commercial laboratory executives know, when a medical group practice is purchased by a hospital or health system, the clinical laboratory test referrals are redirected to the laboratory outreach program of the new owners. That means a reduction in the number of potential laboratory test clients in that regional market.
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May 25, 2010 | Coding, Billing, and Collections, Laboratory Pathology, Managed Care Contracts & Payer Reimbursement
Health insurers not eager to establish coverage for new molecular diagnostic assays
Navigating the pathway to successful commercialization of new genetic tests and molecular diagnostic assays has proven tricky. While scientists work quickly to bring new and better clinical laboratory testing tools to the market, health insurers work at a much slower pace to issue coverage guidelines and establish reimbursement for these new diagnostics tests.
“Successfully moving a genetic test from the research bench to the clinical laboratory takes much more than an understanding of the science,” stated Rina Wolf, Vice President of Commercialization Strategies for Consulting and Industry Affairs, XIFIN Inc., of San Diego, California. “Competition for coverage and reimbursement by health insurers is fierce. Often, the molecular diagnostic tests that win the best coverage decisions by payers are those proprietary tests backed by companies and laboratories with the most effective business plans.”
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Apr 14, 2010 | Laboratory Management and Operations, Laboratory Pathology, Managed Care Contracts & Payer Reimbursement
In the long term, quality measures should elevate recognition of the value of clinical pathology testing
Healthcare quality measures continue to increase, both in numbers and in sophistication. These quality measures offer consumers, insurers, employers, and government health agencies some information about the relative value of clinical services. But the holy grail of quality measures—outcomes data and cost data that adequately reflect patient complexity and environment—is still elusive, say experts.
Dark Daily has long predicted that healthcare quality rating and ranking efforts would boost the fortunes of clinical pathology laboratory testing. Since laboratory tests play an essential role in the diagnosis, treatment, and monitoring of many diseases and health conditions, it stands to reason that physicians would more highly value the knowledge of pathologists and laboratory scientists because it helps them achieve improved outcomes with their patients.
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Apr 11, 2010 | Compliance, Legal, and Malpractice, Managed Care Contracts & Payer Reimbursement
Apparently physicians in several states besides New Jersey are catching the attention of their insurance regulators over UnitedHealthcare’s effort to fine doctors who continue to use out-of-network laboratories. Now, state authorities in Texas, Connecticut, Iowa, Florida, and California have joined New Jersey state regulators by announcing plans to review the legality of the $50 fine announced by United Healthcare for doctor’s who refer their patients to out-of-network laboratories.
In March, the California Medical Association said that this new policy illegally interferes with PPO patients’ right to access out-of-network benefits and improperly obstructs the physician-patient relationship. “Patients have the right to decide where to receive health care services, without having to worry that their physicians are being fined or otherwise penalized for their choices. This right is particularly acute for patients who pay premiums for nonexclusive PPO benefits,” wrote CMA chief legal counsel Catherine Hanson. “And physicians have the right to speak freely with their patients about their health care choices, without having to worry that they will be fined or otherwise penalized should their patients choose an out-of-network option.”
The Florida Medical Association initially asked United Healthcare to take the policy out of its protocols with physicians, but now simply says “We’re confident United is going to be working with physicians not to charge that $50,” said Lisette Gonzales-Mariner, FMA spokeswoman.
United Healthcare spokesman Roger Rollman said that the policy was for “worst-case scenarios” and that fines would not be imposed the first couple of times a doctor didn’t abide by the policy.
American Medical Association spokesman Robert Mills said, “I think, while others [insurers] may have protocols that talk of out-of-network labs, I don’t believe any other insurers are using the stick approach versus the carrot.”
It is not difficult to see that United Healthcare is receiving significant bad press from the medical community on the $50 fine for doctors with patients that use out-of-network labs. This decision has triggered growing concern among doctors, who are worried that they can be made responsible for the actions of their patients. The American Association of Family Physicians has clarified United Healthcare’s new lab protocol and outlined how and when fines can be dispensed, trying to put physicians at ease.
However, it is important to remember that, as part of the 10-year exclusive national lab services contract between UnitedHealth and Laboratory Corporation of America, UnitedHealth has a commitment to take active steps to enforce compliance by its physicians with the laboratory services network. It is believed that the financial benefits to UnitedHealth from this exclusive national lab services contract are significant enough to motivate it to continue its tough stance. What remains to be seen is whether the bad press and negative impact on relationships built with state medical associations will do lasting harm to the long term relationship between UnitedHealth and its physician panel.
Related Articles:
CMA Calls United Healthcare’s New Lab Policy Illegal and Ill-Advised
Doctors upset over insurer’s new policy
AAFP Clarifies UnitedHealthcare’s New Lab Protocol
Dec 30, 2009 | Laboratory News, Laboratory Pathology, Managed Care Contracts & Payer Reimbursement
Sonic Healthcare asks for 30% pathology test fee increase from Bupa and MediBank
In Australia, reduced funding for pathology testing by government health programs is being blamed as one factor contributing to a contract spat between the nation’s largest clinical laboratory and its major private health insurance companies. Pathologists across the globe will recognize several familiar issues, as Australia’s health institutions struggle to cope with increased utilization of pathology testing and higher healthcare costs.
By asking for a price increase of 30% for pathology testing, Sonic Healthcare Ltd (ASX: SHL) has put itself at loggerheads with several of the nation’s largest private health insurance companies. As contracts between Sonic Healthcare and these private insurance companies expire, Sonic then sends bills directly to the patients insured by those health plans for the costs of the pathology testing performed during their stay at private hospitals. The amount of the bill reflects the “gap” fee difference between government reimbursement and the actual charge for laboratory tests.
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Sep 16, 2009 | Managed Care Contracts & Payer Reimbursement, News From Dark Daily
Learn how your pathology lab can collect all the money to which it is legally entitled
Anatomic pathologists who expect to be properly paid for claims they submit to managed care plans are likely to be surprised at how often those claims are reimbursed at less than contracted rates. This issue has become particularly acute during this economic recession, when some payers have become particularly tight-fisted in their approach to settling claims for anatomic pathology services.
“It is not unusual for us to review a prospective billing client and find that the pathology group is being underpaid by a factor of 5% or MORE across the numerous managed care contracts they hold with various payers in their region,” stated Laura Chaney, CPA, Vice President of Operations for Pathology Service Asssociates, LLC, of Florence, South Carolina. “That is a substantial reduction to pathologist income, particularly when the amount of such under-reimbursements may compound over several years.”
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