Credit: Gorodenkoff Productions OU/Adobe Stock
UnitedHealthcare is changing the way it handles claims for routine tests such as diabetes tests and iron tests.
Starting Dec. 1, in most states, the company's commercial health plans, including group health plans, will "apply automated post service, pre-payment policy enforcement to claims reporting laboratory services performed in office, hospital outpatient, and independent laboratory locations," according to a new UnitedHealthcare policy update bulletin for health care providers.
If a provider has tried to increase the size of the claim by taking an unusual approach to billing, UnitedHealthcare may edit the claim to reflect its ideas about what a standard claim of that type should look like.
The new "pre-payment edits" will not apply to tests provided in emergency rooms, hospital observation units or hospital inpatient wards.
UnitedHealthcare is not yet implementing the lab test claim editing strategy in Arkansas, Colorado, Kentucky, North Carolina, Nebraska, Ohio or Rhode Island.
What it means: For UnitedHealthcare, the new policy is a way to hold down rapidly rising claim costs.
For providers, it may feel like more interference in how they do business.
For employer plans, patients and benefits advisors, the policy could lead to more phone calls about problems with lab test claims.
The backdrop: Health care analysts say the underlying cost of medical care could rise by 9% or more in 2026, with claims increasing at the fastest rate in more than a decade.
Other claim-management moves: Cigna said it's implementing a new, previously announced reimbursement policy for claims for high-level patient evaluation and management services.
Cigna expects to edit, or downcode, about 3% of the claims for those services.
Aetna, a CVS Health subsidiary, recently expanded a program that puts some types of claims through an extra level of review. The change affected claims for implants, anesthesia and bundled services.
© Arc, All Rights Reserved. Request academic re-use from www.copyright.com. All other uses, submit a request to TMSalesOperations@arc-network.com. For more information visit Asset & Logo Licensing.