March 2020 ~

Effective May 1, 2020, UnitedHealthcare (UHC) will deny any non-patient lab test claims submitted by hospital outreach labs if billed under the hospital’s facility participation agreement.

As seen in a recent Network Bulletin, any claims paid on or after May 1, hospitals acting as a Reference Laboratory or conducting diagnostic testing for non-patients will not be allowed to bill for such non-patient diagnostic laboratory tests under that hospital’s Facility Participation Agreement. Claims submitted for non-patient diagnostic laboratory tests, or claims where a hospital is acting as a Reference Laboratory, will be denied for failure to comply with this protocol in the event a hospital is billing under its Facility Participation Agreement.

According to a UHC spokesperson, the policy applies to all UHC commercial plans, fully-insured and administrative-services only (ASO). It does not apply to UHC’s Medicare or Medicaid plans.

A recent article in Laboratory Economics estimates that less than 15% of hospital outreach labs have separate independent reference lab fee schedules with commercial insurance companies like UHC. There are also approximately 100 hospital-owned labs with their own distinct NPI that bill separately from their hospital through independent reference lab fee schedules. But the overwhelming majority of hospital outreach labs bill for non-patients using their hospital’s outpatient lab fee schedule.

UHC encourages hospitals wishing to participate in UHC‘s commercial network as a Reference Laboratory to apply to be credentialed and contracted as a Reference Laboratory.

For more information, see UnitedHealthcare Network Bulletin February 2020, Page 16.

Source(s): Klipp, Jondavid, “UnitedHealthcare Requiring Hospital Outreach Labs to Contract as Independent Reference Labs,” Laboratory Economics, p.1, 4-5, Vol 15 No 3, March 2020; February 2020 Network Bulletin;