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Facing Opposition From Labs, UnitedHealthcare, Cigna Roll Back Planned Billing Changes


NEW YORK – The laboratory industry recently notched a pair of wins in its ongoing battle with insurers as UnitedHealthcare and Cigna rolled back billing changes that would have likely impacted lab payments.

But while private and government payors have in several cases throughout the COVID-19 pandemic retreated from plans to put downward pressure on lab pricing, these respites are most likely temporary, said Mick Raich, president of RCM consulting for Lighthouse Lab Services.

In June, insurer Cigna reversed its decision to stop paying for the professional component of clinical pathology. The company had announced in April plans to stop paying for this portion of clinical pathology services as of July 11. The move drew protest from industry players including the College of American Pathologists. CAP noted on June 8 that it had learned that Cigna had decided against the change and now planned to continue reimbursing for the professional component of clinical pathology and that it would be issuing an update regarding this policy in the near future.

Raich said, though, that he expected Cigna would try again in the future to eliminate professional component reimbursement, noting that this was a long-running trend in the industry.

"I've been in the industry for 20 years, and I've watched [professional component] billing slowly but surely erode," he said. "UnitedHealthcare stopped paying it, Aetna stopped paying, then Humana stopped paying it. Now Cigna said they aren't going to stop paying it, but they will eventually."

The professional component of clinical pathology consists of the work involved beyond the running of the assay — for interpretation of test results and preparation of a report for a patient's physician. As Raich noted, many private payors have over the last two decades eliminated or narrowed payments for this component, citing, for instance, the fact that many automated tests do not require professional interpretation.

Cigna is one of the last major insurers to still reimburse the professional component of clinical pathology, Raich said. "But the bottom line is, it's all about shareholder dollars. They will find a way in the next few years to pull this off their balance sheet," he predicted.

UnitedHealthcare also recently reversed course on a decision that had lab anxieties rising. In March 2020, the insurer began rolling out notices of its new test registry protocol, under which labs must register with UHC the tests they offer and include a unique test code for each test they bill the insurer in order to be reimbursed. The company initially set a deadline of Sept. 1, 2020, for labs to register their tests but then extended that deadline to Dec. 1, 2020, due to the COVID-19 pandemic. This month, it announced it was delaying the registry requirements "until further notice," due to the pandemic.

UHC had said it created the test registry in order to gain better visibility into what tests it was paying for and to provide its members better information on test availability and costs. The insurer rolled out a similar registry for genetic testing in 2019, but the move to expand it to more routine testing met with pushback as labs, especially smaller independent labs and hospital outreach facilities, expressed concerns about the administrative burden involved in creating and maintaining a new set of test codes for billing UHC.

Raich noted that the test registry also would have provided UHC with a tool that could help it more easily identify bills coming from out-of-network labs. "It's another way to limit payments of out-of-network testing," he said. "That's the goal."

He said he thought the insurer would relaunch the program at a later date.

Speaking to 360Dx about the program last year, though, Kyle Fetter, chief operating officer of Xifin, predicted that UHC would ultimately decide the registry was more trouble than it was worth and would walk it back, a prediction that currently looks fairly prescient.

Raich said COVID-19 had made payors, both private and government, more reluctant to make moves that could be perceived as limiting patient access to testing, citing as another example the postponement of cuts under the Protecting Access to Medicare Act of 2014.

"That's the narrative right now," Raich said. "Patients are number one, and they need to have access" to testing.

He predicted, though, that efforts to push down lab pricing would continue on the other side of the pandemic.