The American Hospital Association (AHA) has approached the Centers for Medicare & Medicaid Services (CMS) against a new program of private payer UnitedHealthcare. AHA wants a stay on the implementation of the Designated Diagnostic Provider program citing it would restrict in-network diagnostic providers. AHA has sought the intervention of CMS in UnitedHealthcare’s Medicare Advantage, Medicaid managed care, Children’s Health Insurance Program and Health Insurance Marketplace health plans.
- To ensure cost-efficiency and high-value care, the Designated Diagnostic Provider program covers outpatient laboratory services provided by freestanding or hospital labs. In a letter to CMS, AHA’s executive vice president of government relations and public policy Thomas P Nickels has mentioned that the program poses a threat to coverage for diagnostic tests at most freestanding and hospital labs.
- “This policy would result in substantial confusion among patients about which providers are covered by their health plan, and, as a result, also likely increase the incidence of surprise medical bills that will not be prevented by recent changes in federal law,” Nickels writes.
- According to AHA, incidences of surprise bills are likely to increase due to the program as some labs may seem to be within a patient’s network despite not earning Designated Diagnostic Provider status according to UnitedHealthcare’s policy.
- The hospital group also wants scrutiny of another UnitedHealthcare plan that purportedly limits specialty pharmacy coverage. The group has pointed out new policies that don’t allow some providers to acquire and store a variety of drugs. AHA further seeks CMS to prohibit the use of “white bagging” and “brown bagging” of prescription drugs.
- The letter says the program makes providers accept drugs purchased and handled by the health plan, which in turn relies on the OptumRx chain of owned and affiliated specialty pharmacies.