I’m having a tough time getting mad at United Healthcare. The huge managed care company is under fire for penalizing docs who use any lab other than UHC’s preferred partner, LabCorp. The AMA, regulators, individual physicians, and a few consumer groups are all screaming about UHC’s heavy-handed, dictatorial infringement on their right to practice medicine.
They’ve got it all wrong.
Last fall LabCorp and UHC signed a 10 year deal naming LabCorp the exclusive diagnostic lab provider for UHC’s insureds.
The deal makes sense for UHC, UHC’s employer customers and insureds. Insureds in an HSA plan will see lower out-of-pocket costs; employers’ health care costs will be slightly reduced, and UHC will make more money (which could be used to reduce premium increases…really). By consolidating all lab records with one provider, UHC’s data mining and analytics will be enhanced, potentially strengthening the company’s disease management efforts. (although UHC is certainly big and smart enough to take in data from multiple partners, this would make it somewhat simpler and more efficient)
Perhaps LabCorp was not getting as much volume as they expected, or maybe this was part of the plan all along. For whatever reason, UHC recently announced that it would consider penalizing it’s contracted physicians if they referred patients to other labs – with fines, contract termination, or reduced reimbursement.
Docs are complaining that LabCorp does not provide a few highly specialized tests, could disrupt patient care and could harm the physician-patient relationship.
The docs are missing two key points.
First, the golden rule applies (no pun intended) – he who has the gold rules. And in this case, UHC has the gold. As a dominant health plan, they can make rules, albeit that are legal and ethical, about how they will administer a plan.
Second, each physician contracted with UHC, or for that matter any other health plan, has agreed to comply with the health plan’s referral guidelines, including a requirement to refer to other providers within network.
Finally, many (but certainly not all) physicians aren’t concerned about their patients’ out of pocket payments for these tests.
That’s got to change. Physicians simply have to consider costs – their patients’ and employers’. This “let them eat cake” mentality is not helping their cause, nor is it enhancing their standing in the health policy debate.
Joe, The ends that UHC wants to achieve are very understandable.
It the means that are the problems. The answer is carrots, not sticks. Sticks DO NOT WORK with doctors. Sticks will only piss off the doctors and further erode an already tenuous relationship.
Please see my further thoughts at http://e-caremanagement.com/doctors-and-health-plans-can-care-management-opportunities-reconcile-the-hatfields-and-the-mccoys/.
Vince
Joe, I’ve been reading your blog for a while now and I’m really surprised on your take on the UHC non network lab policy which I disagree with for a number of reasons. UHC’s non network lab policy is way over the top and goes beyond what’s necessary to incent consumers to use network labs ( or their providers to encourage in-network lab use). First, remember that this applies to PPO plans not HMOs. When consumers sign up for PPOs, they usually pay more and do so largely for their ability to CHOOSE their providers; including in some cases a non network lab/provider if they prefer the convenience or if their doctor suggests that a particular lab does a better job on a particular test than the network lab. We are forgetting a few fundamental things here: doctors may refer, but consumers choose where they want to go. I’ve never gone to the lab my doctor suggested. Once I have the order in hand, I can go where I want ( even if it is usually to my insurer’s network lab).
Further, you are failing to recognize the coerciveness of such a policy. We need to recognize that the wars that are currently flaming between providers and health plans, such as United, are very detrimental to our ability to make improvements that would benefit consumers and employers, add costs related to disputes over the wrong issues and further degrade the ability of providers and payors to work constructively to solve the thousands of serious problems we have in health care delivery.
Certainly health plans should get the best buy they can from providers in their network; but they should stick to plan incentives aimed at the insured/ consumer. After all, in PPO plans, we still have the right to use our non network benefits and we shouldn’t have to worry about our doctor’s being penalized. If you believe that United won’t penalize doctors when they see their patients using out of network labs, you don’t know this company very well.
Lastly, if you really believe United will use the additional ” savings” from their lab deal to reduce premiums,I just think that’s wishful thinking and a bit naive.( have you noticed the profit levels and stock option deals this company boasts ?)
Andrea – thanks for your comments and thoughts.
Couple reactions. First, as an alum of UHC, I’m very familiar with the company, and as a reader of the blog, I’m sure you’ve noted I’m not exactly a fan of everything they do. I’ve taken them to task several times.
Re using savings to reduce premiums, that isn’t naive, that’s business. If they can lower their cost of goods sold, they can take share profitably from their competitors. Yes, they may add to margins due to a lower medical loss ratio, but it is all about share in this business, and this will enable UHC to lower price while maintaining margins.
Second, my belief is the physicians drive most of the decisions about utilization; this policy incents docs to think about costs. Most consumers do what their docs tell them, this policy recognizes that reality.
Finally, I’d say that docs just have to start thinking about cost. When you read the HSC study referenced in the post, you’ll see that few docs do worry about costs. It is because they don’t that this type of policy is coming about.
Joe
Joe,
Thanks for this post. I thought I was the only one on United’s side in this debate. Certainly we could all follow Andrea’s example — that is, damn the costs, I’ll do what I please. But that’s treating healthcare as though it were a resource of infinite supply. Obviously, in that scenario, the laws of supply and demand being what they are, costs will increase toward infinity as well.
Which is what they are doing.
Which is the problem.
I think it would be helpful if both Medicare and private insurers could track utilization by both provider and referring doctor. If a given doctor is identified as a high utilizer, he or she should be challenged as to why utilization far exceeds best practices. If practice patterns cannot be improved within a reasonable timeframe, perhaps removal from the network would be an appropriate sanction.
Right on, BC. And I must confess that either I am becoming one dorky individual or we are in a dysfunctional society when someone advocating accountability gets me excited.
UHC does track its doctors’ utilization of drugs, tests, etc to the best of its ability. All private insurers do so using billing data. They use the data to determine quality and efficiency ratings for their network’s doctors. So far, it’s just data collection. Pay-for-performance plans will use such data for the application of carrots and sticks in the near future.
The next step is for UHC to require primary care doctors to only refer to the lowest compensated specialists. This is just another managed care move to push more of their administrative costs on to the physician. In 20 years there will be a health care crises because there will be very few doctors. Still, no one will feel sorry for the rich doctor who went to school for 25 years and finished residency with 100K of debt. You can blog and ‘discuss’ all you want, but insurance companies are destroying health care in this country.
“insurance companies are destroying health care in this country.”
And all we have to do to fix it, is have the federal government rescue us. Why is that so hard for people to see?
“And all we have to do to fix it, is have the federal government rescue us. Why is that so hard for people to see?”
Not a solution – the insurance lobby owns the government.
Hi:
My adopted son suffers from emotional problems and mental health issues. Seven days ago, with hospitalized him for depression. Yesterday I get a call from the hospital saying that United Health Care is going against the hospital psychiatrist reccomendation of continue in-patient. My son is still suicidal according to the hospital, however, the case manager at UHC is telling me that they need to move him to outpatient. She, who is not a doctor and the insurance company’s doctor (who has not seem him) are saying that my son is going to have to be discharge from the hospital and that they will only pay for outpatient. Meanwhile every body that has seem him, including me, knows that he is suicidal. At what price do they continue to cut costs…he is entitled to 20 days inpatient….I am not looking to use the entire 20, just enough to get his medication in place. They are horrible, UHC staff could care less about my son’s safety….and only care about their pocket books and that of their stockholders.
Suggested reading:
The Circus of Medicine. Lima, OH: Wyndham Hall Press.
by Richard Dean Smith
Medical practice received uncharacteristic sanction and public approval during the middle decades of the 20th century. For centuries before and decades since, medicine has been the focus of criticism and distrust. Throngs, droves, herds, flocks, legions of self-appointed critics, pricey ‘healthcare’ consultants, economists (academic and otherwise), on-the-run politicians, and promoters of the healthcare insurance industrial complex brought bizarre exaggerated claims against the medical profession. Nearly everyone has opinions on ‘what’s wrong’ with doctors, hospitals, and medicine—a new / old breed of hangers-on surround medicine; such as, some rabble healthcare consultants throwing dice on a blanket in the hospital parking lot, some misguided influential academic healthcare economists dealing three-card monte on the front sidewalk, some less than objective medical journalists hustling a shell game in the hospital foyer, that is, a pervasive new form of healthcare quackery. A result was the managed care mass medical movement.
Literature of past centuries shows that medicine has always been surrounded by a circus: promoters, jugglers, swindlers, con-men and women, charlatans, imposters, poseurs, humbug artists in the School of Indictment opposed to ethical practicing physicians. Purveyors of not just bad advice, but worse. Robert Morris says: “Some of the most responsible doctors will always be in the hands of financial fakers, and some of the most responsible business men will always be in the hands of medical fakers,” and healthcare consultant fakers. In the 19th century, Worthington Hooker said, “It is folly for the physician to boast that he worships in a temple, upon whose altars no strange fires ever burn, while he looks out with contempt upon what he regards as the almost heathenish observances and worship of the unscientific and unlearned people.”
The “intellectual underpinnings” of managed care form a Noodle’s Oration: a superficially plausible argument consisting entirely of fallacies and logical errors. Oliver Wendell Holmes said, “There is a class of minds much more ready to believe that which is at first sight incredible, and because it is incredible, than what is generally thought reasonable: Credo quia impossibile est.” Historian James Harvey Young says: “The quack has been adept at erecting a beautifully logical structure on the basis of a single false but plausible premise. Numerous educated men have missed the premise, admired the logic, and been trapped.”
In the presence of woodenheadedness that permitted rapid adoption and excited growth of managed care, the mass medical movement of managed care flourished unrestrained. Failure of the popular press, failure of ‘learned’ journals, the fallacy of self-assumed authority of the healthcare consulting industrial complex, and lack of responsible inquiry by the academic community (whose tenure intended to prevent such atrocities against human reason) supported the irrational, foolish movement into managed care: “Knaves there will always be, and fools—whatever the justification for their folly—and, therefore, pseudo-medical deception.” The self-trumpeter’s fallacy became the creed and modus operandi of the managed care mass medical movement.
While medical practice is solemn and serious, humor and satire may neutralize madness of the mass movement of managed care: satire consists: “not of mirth, but of the intense and even painful sense of the absurd.…where it is vice rather than folly that is the target, or folly so noxious as to amount to vice—and provoking reactions that vice engenders but not mere folly—we are in the presence of Satire,” and thus, the modern Circus of Medicine.
Links:
wyndhamhallpress.com
richardsmithmd.com
All I can say is that ever since this deal with Labcorp went into effect, my regular lab tests, that I really need in order to know if I’m OK or not OK, have been flaky at best. To be more specific, Labcorp, without regard to where blood is drawn, has time after time failed to provide all the test results, or sometimes provides them weeks late. They blame the clinic for not handling the specimen properly or not delivering it on time.. yada yada. One time they sent a report with a critical test result omitted – no explanation at all. Where the number should have been was just blank. This kind of thing was extremely rare up until recently. Now it is extremely rare – unheard of in my experience – for me to get all the results that were ordered by the doctor. What changed? The lab.
If even a few people have a bad outcome because their doctor didn’t have the right information when needed, the financial consequences, even excluding lawsuits, are going to offset the gains of cost savings in my humble opinion. Plus doctors are just getting disgusted and refusing to do business with Labcorp regardless of the consequences. Mine did just that. They can’t afford to work with a crappy lab. Quality matters, and not just the word quality in a press release. Actual quality work is not optional in this business, because without it, people will get sick and die.
Here’s my theory about what is going on (call me a cynic). Labcorp took on the UHC contract, but knowing they were losing the Aetna contract, decided not to ramp up operations and staffing to handle both contracts simultaneously. For several months at least, their facilities are overburdened and unable to keep up with the volume. They are not delivering good quality service to anyone, at least in some areas. If this is the case, we can logically hope to see an improvement in Labcore’s performance eventually. Meanwhile, what is the price in terms of human lives and suffering, not to mention dollars? I could reasonably argue that my life and health was seriously negatively impacted by this bullshit. I lost time from work and was hospitalized ($1700 billed to UHC), all of this might have been avoided if I just had the information I needed from the lab. Perhaps I should sue.
I have been reading all of the messages on this list. I usually do not respond, just listen. I have worked in the medical field for 30 years. I have seen the quality of care go from good to bad. People always try to blame the physicians for all of the cost and expense because they may live in a better house or drive a better car than they do. I am sorry but I pay the bills in a physicians office and the bottom line is hard to cover. People have no idea the expenses that a physician has to pay just to keep the doors open. They order care for patients that they assume the insurance will pay since that is the normal procedure followed by all physicians. Then we submit the bill. They use stall tactics like we did not receive the claim even though the electronic submission of claims was supposed to revolutionize medical billing. Well we have reports saying they were received by the company but they insurance company says no, they did not receive. Does the doctor have any recourse? By the time that we go back and take staff time to ask for a review from the insurance company we have wasted man power that is needed for our patients. We see patients all day long and then we have to do paperwork once they are gone. Now, I know there are some doctors that will charge extremely high fees and they usually get them but the most of the physicians that I know try to economize for the patient. We have to check cost for prescriptions and know which ones you can get cheaper and then the insurance will come along and find some reason to find a way to not pay for it. I have had children needing certains specialty tests to be done, filed a pre-determination with good reasons to do the testing and been denied. They say you can file another request for review but by the time we do that 1-2 months from then the patient is sitting waiting to be treated and sometimes with life threatening circumstances. Also they have probably gone to many other doctors trying to find the solution and run up more bills than it would have been to do the testing recommended by the physician. The doctors offices are required to do more and in that we have to by expensive computers and software in order to try to play the game with the insurance company to see if they can get the claim paid or not. AND, when the claim is denied and we have provided a service that say cost $300.00 to $400.00, who eats the charges and pays the fees for the labs or supplies needed for the physician to treat the patient. The doctor does. I have seen so many of the doctors that I work with pay for patients to have work done or see the patient for free because they know they cannot afford it. I think everybody is forgetting, THERE ARE GOOD PHYSICIANS IN THE WORLD. THEY ARE NOT ALL AFTER MONEY. It is like everything else. There are good ones and bad ones. I know a lot of excellent doctors that are about to go out of business because they insurance companies are charging outrageous amounts for insurance and then finding ways to not pay claims is a way of habit and one is UHC. Also when they make a mistake they have to “form a committee” to look into the matter and they take their own good time about it and while they do that the doctors office income is restricted to the point they have to lay off people. I thought I would never be laid off from a physicians office. I was. That was the hardest thing I had to take was that. I know how the insurance companies make money and we are just trying to make ends meet and we provide a lot of people with salaries. They are not extreme salaries and these people have to be trained in order to provide the services they do. But does anyone care about that. No they only want to blame the physicians. Does anybody ever think about the malpractice insurance and how much it costs every year that a doctor has to keep up or they can’t see patients? No one does. They only see what they want to see. I am tired of people blaming the physicians. There is more than one side to the story and it is about time some listened to both.
I work for a health care provider, can anyone tell me why so many foreigners are assisting me with claim questions at UHC? I simply cannot understand them!
UHC has call centers all over the country and in foreign countries as well. It’s really just a matter of were your call gets routed to.
On another note . . . do all of you here realize that most of the policies that UHC administrates are for self insured companies that get to decide what gets covered in their policies and what does NOT.
UHC follows fda guidelines to pay all claims, but if the employer decides that they are not going to cover something then that is the end of it. Except of course for the few things that are mandated by the federal or state government those mandates have to followed by all plans. For self insured policies the money that is paid out on claims is actually the money that belongs to the employer not United Healthcare. United Healthcare is paid to administrate the policies and pay claims for the employer using the employer’s money.
Take it from someone also with lots of experience from all perspectives of this topic. It s a bad deal period, especially for a PPO to dictate providers, but it is essential for doctors to have immediate access to labwork. This is always best for the patietn. Bottom line… more money for insurance company, sub-standard care for patient, and out of the control of the treating physician. They could easily save money by just negotiating for lower reimbursments for lab services, bad deal… sorry.
I have Aetna insurance through COBRA and it is up at the end of this month and thye will not let me buy coverage. So I am taking a guaranteed issure from United Health. With Aetna, we use to have Lab Core, but about the time UH signed a contract with Lab Core, Aetna went to Quest. Lab Core lost a big contract in losing Aetna. Sine I have experienced both, I do like Quest better.
I work for UHC Customer Care which is outsourced to India site i have come across lot of providers that compliment on customer care in India as they have more knowledge than what the onshore reps have……sorry do not wanna descriminate……just trying to post sumthin’…..
I got a letter from these guys saying “in order to improve service and make things more convenient…” then went into how they intend to charge Me triple what they would ordinarily pay, if my doctor persists in using one of the two labs they named that they’ll be refusing to pay, but without bothering to tell me which labs they DO use. Bastards.
That’s why I’m online now — trying to find of list of labs approved by United so I can present it to my doctor. Believe me, I don’t feel comfortable with making this type of suggestion. I don’t think it’s my place and it makes me despise United.
I don’t think it’s fair dragging me into this dispute United has with my doctor over which lab he chooses to use. It’s none of my business. I strongly resent being blackmailed by being informed that I’ll have to pay whomever they refuse to do business with. Triple an amount United deems fair. How do I know what factors go into my doctors choice of labs? And this whole “in order to improve … and make convenient …” b.s. just pisses me off.
They’re unlikely to drop dead anytime soon so there’s little hope in wishing for such a thing, but just in case there is, I do hope fervently United drops dead.
I’m off. To look for approved-by-United labs, having been successfully maneuvered into doing United’s bidding. Let’s see how difficult they manage to make that. Bastards.
Ok, regarding the comment that the reps in India are MORE knowledgeable than the ones within the US: I don’t think so. I have worked for 20 years as a billing manager and UHC outsourced reps are by far the worst to deal with. They can only read from a script or read from the EOB. Anything beyond that, they will give you a reference number and then proceed to either do nothing or get the claim rejected again. I don’t blame the individual people: They do not have our healthcare system and they are not trained properly.
Does this mean that if you belong to United Health Care and your doctor sends you to another lab, UH will not pay for the lab work? What if you are in a hospital and have no choice of which lab is used?
Please help, I don’t want to join UH if this is the way their policy works. No one told me about this.
comment for cindy prochnik; i work at uhc and have an answer to your question. If your dr ships your lab work out to a lab for testing it is out of your control as the member. Therefore the plan will process the labs claim at an in net level of benefits as long as the referring dr is in net. If your plan is self-funded (employer wrote your benefit plan and pays claims w/ their own money) they would have to purchase this administrative option.
If you are admitted to a hospital or facility type setting any lab work done in the hospital is all inclusive to the facility payment and would be processed at an in network level as long as the facility is in network. If you get lab or pathology bills when you were in the hospital, call uhc to get those paid for you. Alot of times the claims processing system doesn’t know to process those claims in net, in which there is a logical explanation for.
Joe,
UnitedHealthcare is the WORST.
It is my job to BEG UHC to pay claims; it is like begging because if and when they pay, it is pittance.
They have the lowest reimbursement rate, the highest processing error rate (~25%), and are the hardest to contact for resolution.
Jthigpen knows of what I speak.
And to Susan, I can’t understand them either; when you finally do understand, it doesn’t matter because they can’t do anything but read the eob to you.
The anjum dhongre posting should serve as an example of communication problems; or was it a joke?
Messages left with “network administrators” are not returned. They don’t even respond to registered letters.
We eventually had enough but had to wait for the contract anniversary to leave the network. They even screwed that up! Now they’re processing error rate is 100%. Services rendered when In Network are processed Out of Network; but no one will respond. (But their website continues to have provider listed In Network when he is OUT of Network.)
There are numerous points you have overlooked. To list a few:
1. The contract is between the insured and the insurance company. The insured (the patient) rarely takes responsibility for insurance info. Often we are given outdated insurance info. Again, it is the provider that must employ staff to check accuracy of insurance info. And it is the responsibility of the patient as an active participant in their care to inquire about labwork and referrals.
2. Employers change their insurers/ networks often and at random times of the year. That employer may have changed from a network we are in to one that we are not in; or vice versa. The networks do not contact us to inform us when they lose a contract. It is only after rejection and several phone calls that you might find the problem. Yep, provider pays for that too.
3. Network participation is a financial arrangement between the provider and the insurer. Payment for provider services rendered to the insured. The physician is not rendering services when he orders lab tests, nor is he rendering services when referring to another physician. Patients are referred for that doctor’s expertise; network participation has no role in referrals. Same for the labs. Do you think patients would be better served if docs limited referrals and orders to “in network”?
You may be familiar with UHC but you are woefully lacking in knowledge regarding best medical practices and physician’s responsibilities.
I believe there is an antitrust lawsuit against UHC regarding this matter in Ohio.
4. Should we have UHC patients tatooed? Just so we’d know where to send them? At least where to send them this week? Is it still Labcorp?
We treat patients according to their individual medical need. The provider is not a party to the UHC lab contract, or to other network participant choices, or to the insureds particular plan (see #1).
5. UHC is big but they’re not the only.
Tell me, what makes them special?
6. Don’t even get me started on out of network reimbursement. See New York State lawsuit.
You’re right, UHC makes their rules.
But they choose to ignore some other rules (aka LAWS) since it costs less to pay the fines for breaking the law than it costs to follow the law. That’s cost effective alright.
But ETHICAL? I don’t think so.
Premiums are UP, copays are UP, deductibles are UP. BUT the providers are paid LESS. Where’s the money going? I’m betting it’s going to UHC CEO, UHC shareholders and probably HR kickbacks.
Before I forget, If you think socialized medicine, aka single-payer system, would be better, you’re clueless. Is the DMV or the IRS working out for you?
In closing, if we practiced medicine the way UHC “manages”, we would be guilty of malpractice!
I am beyond pissed at UHC right now. I was referred to this awesome doctor by a friend who works with me. we both decide to get check ups because we wanted to start getting healthy and I NEVER go to the doctor unless I am sick.. mostly because I am afraid of what they will charge me and etc. So I look him up on my UHC website and alas, he is in my network and actually a cost effective Dr. Woo hoo. I go there.. the guy is great. They called UHC to verify my insurance and I went ahead and got tested to make sure I did not have Diabetes. The doc said that it was covered in the visit.. so no problems. 2 weeks later(last week actually) I get a EoB from UHC showing I went to Quest Diagnostics and owe $270ish. My friend didn’t have this happened.. and we both got lab work done. So I wait to call until Thursday… I checked the website one more time and I got ANOTHER EoB on the way for quest again… now I owe $500. I call and they just tell me that Quest is out of network. well.. no duh. I see that onthe EoB. I went to a In network doctor.. who said it was covered. The guy just fell silent and said there was nothing I could do. Even if I did the appeals process it would still come back as showing that the transaction was done correct and the doctor should have used an in network doctor. I am severly PISSED. I am calling the doctor tomorrow and I will call uhc every freakin day until this is resolved. This is complete BULL SHIT. You go to a doctor that is in network, the doc says it is covered, and you get this bull shit coming back to slap you in the face a couple of weeks later. bah…
I had a stroke last year and have been home since dece 07, For some reason my wheelchair was rented, not bought and now uhc is balking at paying the rent, they are also saying I don’t need more PT or OT – I guess walking and learning to use my arm isn’t important to them, but it is important to me. Also, the muscles in my shoulder are gone and it just hangs down, pulling my shoulder out of socket and they refuse to get me an arm sling, because it isn’t medically necessary, it would only help reduce the pain I get when i stand and my arm hangs limply
I must agree that UHC reps are the worst to deal with. Just a giant waste of time. Now it seems UHC’s solution is to make the reps use fake american names! Try hiring americans that can do the job correctly. When we call an ins. co., we need help on a claim, not a per son that is trained only to read from a script, but someone who actually understands how to resolve a problem! Shame on UHC for making it so hard for a medical provider to resolve billing issues.