Designated Diagnostic Provider Update from UHC

Designated Diagnostic Providers update from UHC by AIMA Medical Billing Coding

Designated Diagnostic Provider Update. The AIMA medical billing team draw your attention to a recent update from UnitedHealthcare which relates to laboratory services effective from July 1, 2021.

UHC recently announced plans to implement the Designated Diagnostic Provider benefit designs. For fully insured commercial plan members, outpatient laboratory services will only be covered when delivered by freestanding or hospital lab providers who meet certain quality and efficiency requirements.

Effective from July 1, 2021, participating labs must complete a Lab Quality Questionnaire. While this currently only impacts pathology groups and laboratories (hospital-based and independent labs), Designated Diagnostic Provider requirements will be expanded to include major radiology services, such MR, CT, PET/Nuclear Medicine, in 2022.

As per their website, UHC state,

“In an effort to reduce member cost and improve transparency, we’ve created, subject to state regulatory approval, Designated Diagnostic Provider benefit designs. For fully insured commercial plan members, outpatient laboratory services will only be covered when delivered by freestanding or hospital lab providers who meet certain quality and efficiency requirements.”

Designated Diagnostic Providers 

Designed to support UHC members in choosing cost-effective and high-value care providers. Effective July 1, 2021, and subject to state regulatory approval, outpatient diagnostic lab services will only be covered for members with UnitedHealthcare Designated Diagnostic Provider benefit designs if delivered by Designated Diagnostic Providers. Services may not be covered, and patients could be responsible for payment if performed by providers who are not designated. UnitedHealthcare will build out access as necessary to help ensure all members and physicians have access to Designated Diagnostic Providers.


Non-Designated Diagnostic Providers 

Will remain in-network with UnitedHealthcare, but outpatient diagnostic lab services will deny as non-covered for members with Designated Diagnostic Provider benefit designs and your patients may be liable for charges. The Designated Diagnostic Provider benefit designs will not apply to lab services rendered as part of inpatient admissions, emergency room visits or outpatient surgery pre-operation testing that is billed as part of a global surgical package.

Why Designated Diagnostic Providers?

UHC claim they are continuing to work toward the Triple Aim of better care, better health and lower costs for UnitedHealthcare members. 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. 

It is UHC’s belief that when you help patients choose health care services that are high quality with less cost, they are more likely to get needed care and be more engaged in improving, maintaining and managing their health. 

AHA Protest to Designated Diagnostic Providers Policy

In a letter dated February 4th, the American Hospital Association (AHA) urged the Centers for Medicare & Medicaid Services CMS to disallow the implementation of the DPP policy in products that it oversees. The letter emphasized Under UnitedHealthcare’s DPP program, a lab may be listed as being in-network but, in reality, the plan will not cover services provided by the lab. This undermines the patient’s understanding of their network and likely the contractual agreement they have signed with the insurer. It also could mislead state and federal regulators about the sufficiency of the health plan’s network. You can read the full letter here as well as a response from industry publication Becker’s.

How does this affect your healthcare business?

The AIMA team will work with all of our affected clients to seek an understanding of the potential impact of this new UHC requirement on both our In-Network and Out of Network Laboratory Clients, Medicare Advantage Plans and also what is required to become a ‘Designated Diagnostic Provider’.

Contact the AIMA team today to learn how this new update affects your healthcare business.