Non-Participating Lab Practices: Waiving or Capping Member Cost Share Prohibited

UnitedHealthcare’s laboratory network includes more than 1,500 clinical reference laboratories to support patients. Network care providers are expected to refer their members to network laboratories for clinical lab and anatomic pathology, unless otherwise authorized by UnitedHealthcare consistent with their participation agreement. Some nonparticipating labs attempt to attract customers by waiving or capping copayments, coinsurance or deductibles. Such arrangements undermine the benefit plan by eliminating incentives created to encourage members to choose to receive care within the network and to discourage overutilization of services. UnitedHealthcare benefit contracts exclude coverage for any out-of-network lab services for which the provider waives the coinsurance, copayments or deductibles. In addition, routine waiver of coinsurance, copayments or deductibles may be a violation of the Federal False Claims Act, subject to investigation by the Office of the Inspector General and/or any applicable state insurance department’s fraud division.

Source: https://www.unitedhealthcareonline.com