AHA Decries UnitedHealthcare’s Diagnostic, Drug Coverage Policies

The American Hospital Association (AHA) is seeking immediate relief from UnitedHealthcare’s new benefit design program that would restrict in-network diagnostic providers.

The hospital group called on CMS to exercise its oversight authority over Medicare Advantage, Medicaid managed care, Children’s Health Insurance Program and Health Insurance Marketplace health plans to prevent the private payer from implementing the program dubbed the Designated Diagnostic Provider program.

UnitedHealthcare recently introduced the program meant to ensure cost-efficiency and delivery of high-value care by covering outpatient laboratory services provided solely by freestanding or hospital lab providers who meet certain quality and efficiency requirements.

However, AHA is arguing that the program “could eliminate coverage for diagnostic tests at most freestanding and hospital labs while continuing to portray these providers as ‘in-network’ to health plan enrollees.”

“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,” Thomas P. Nickels, AHA’s executive vice president of government relations and public policy, continued in the letter to Acting CMS Administrator Liz Richter.


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