Miami physician asks why UnitedHealthcare requires use of the BeaconLBS system for authorization for recommended medical laboratory tests that may help identify lymphoma early
In Florida, the confrontation between one of the nation’s largest health insurance corporations and physicians, clinical laboratory managers, and pathologists continues. The source of this confrontation are the restrictive and burdensome requirements for medical laboratory test ordering imposed last fall by UnitedHealthcare (NYSE:UNH) and administered by BeaconLBS, a business division of Laboratory Corporation of America (NYSE:LH).
For Florida rheumatologist Olga Kromo, M.D., UnitedHealthcare’s new decision-support system that physicians are required to use when ordering clinical laboratory tests is highly flawed.
Restrictions on Ordering of Medical Laboratory Tests
Other Florida physicians have pointed out that UHC’s BeaconLBS system is onerous, time consuming, and difficult to use. But Kromo goes still further, saying the BeaconLBS system could have an adverse effect on patient care and increase negative outcomes.
In an interview with The Dark Report, Kromo explained that patients with connective tissue disease are at higher risk for other serious health conditions such as lymphoma. This is true for those lupus patients with systemic lupus and patients with Sjögren’s syndrome, both chronic autoimmune disorders. For these patients, frequent clinical lab testing is a required as part of their standard of care.
If ordering these medical laboratory tests is overly complicated or time consuming, she said, then patients may not get tested as frequently as is needed for their physician to identify complications and spot the signs of lymphoma early. Kromo is one of four physicians in the Arthritis and Rheumatic Care Center in Miami, Florida.
Monitoring Lupus Patients with Clinical Laboratory Tests
“Among our patients who have lupus and uncontrolled Sjögren’s, which is very common, there is a high risk of developing lymphoma,” Kromo said. “A clinical laboratory test is recommended for timely monitoring of these patients, but UnitedHealthcare says that BeaconLBS must pre-authorize the test before we can run it. If long-established clinical guidelines specify that a test is recommended for lupus patients with Sjögren’s, why should we physicians have to request authorization from a health insurer?
Kromo has raised a serious issue as to why UnitedHealthcare and its contractor, BeaconLBS, are interposing themselves between physicians and patients when physicians—following widely accepted medical guidelines—are ready to order medical lab tests that UHC requires to be pre-authorized. Multiple state and national medical societies have written letters to UnitedHealthcare objecting to this interference with established medical standards of practice.
Interfering with Appropriate Patient Care?
Along with the issue of interfering with the established practice of medicine, Kromo has an equally serious issue with UnitedHealthcare’s laboratory benefit management program. It is the lengthy time needed to use the required BeaconLBS system and the fact that—because there is a limited number of electronic interfaces between BeaconLBS and electronic health record (EHR) systems—physicians must enter orders for tests twice: once to obtain pre-notification, and once to enter the order in the EHR.
“Just the process of requesting pre-notification and pre-authorization for this test through the Beacon system is an immense hassle, meaning it could prevent rheumatologists from ordering this test,” explained Kromo.
“UnitedHealthcare may be concerned because this test is expensive,” she added. “But it is a necessary test. If rheumatologists don’t order this test, patients with lymphoma will not be identified until they have stage-three or stage-four cancer. This is an important patient care issue.”
Kromo may be pointing out a more serious problem that rheumatologists have with the BeaconLBS test ordering requirements. The American College of Rheumatology estimates that about 400,000 to 3.1 million adults in the United States have Sjögren’s syndrome. For these patients, blood tests can determine the presence of antibodies that are typical among these patients, including anti-nuclear antibodies (ANA), and serum free kappa and lambda light chain testing to help make the correct diagnosis of the disease.
BeaconLBS Pre-Notification List Includes Serum Free Kappa and Lambda Light Chain Testing
To ensure that these patients have not developed lymphoma, Kromo said, rheumatologists will do free kappa and lambda light chain testing, for which UHC now requires pre-notification. “This particular medical laboratory test is of a much greater level of clinical importance from most of the tests listed under the BeaconLBS system,” she explained. “To get the test approved, the physician has to answer a number of questions and then wait for them to pre-notify the test. It’s a big problem.”
In addition to the patient care concerns, Kromo is like other physicians who have found the BeaconLBS system to be so difficult that those in her four-physician practice are not using it. “When we tried using it, we found it to be an incredible hassle. Just unbelievably onerous. Now we’re not using it at all. We actually have a workaround with another lab, and, so far, that has worked for us,” she explained. “Many physicians in South Florida are using that same workaround.”
In Kromo’s practice, a phlebotomist is available to draw patients’ blood as a convenience. “After we draw the blood, we forward the samples to patients’ labs depending on their insurance,” Kromo said.
Added Paperwork Means More Hours per Day for Physicians’ Staff
If Kromo’s rheumatology and arthritis practice used the BeaconLBS system, the phlebotomist would need to stay an extra hour to two every day, she estimated. “Just the paperwork for Beacon takes about 20 to 25 minutes per patient should a patient need lab tests. Because about 95% of our patients need lab tests on almost every visit, it’s obvious how this system disrupts patient flow in our office,” Kromo said.
“In fact, our lab person was so upset about the need to do all this extra work that she almost quit,” Kromo said. “And this is someone who has been with us for seven years.
“We tried to figure out what it would take to comply with this Beacon requirement,” continued Kromo. “The UnitedHealth people told us to have the staff take an extra one to three hours at the end of the day. They also told us we had to hire staff just for this BeaconLBS system. This is a difficult problem for us and those are terrible answers when we already face increased hassles from every insurance company and reimbursement cuts from Medicare,” she concluded.
Neither BeaconLBS nor UnitedHealthcare responded to requests for comment to this article.
In the latest issue of The Dark Report (dated February 17), Florida physicians describe how they are resisting UHC’s efforts to implement the BeaconLBS system. Since October 1, 2014, UHC has required physicians to use this new decision-support system when ordering medical laboratory tests for UHC’s commercial HMO patients.
Physician Non-Compliance Means UnitedHealth Will Not Pay Medical Labs
UnitedHealthcare’s laboratory benefit management program requires physicians to obtain pre-notification or pre-authorization for 82 lab tests. If the physicians fail to do so, the clinical laboratories performing the tests will not get paid, and the physicians who ordered the tests may face penalties. Currently, UHC has not implemented the penalties under the BeaconLBS program and has not said when it will initiate what it calls the “claims impact” phase of the program.
In the meantime, some specialist physicians in Florida are sending patients back to their primary care physicians along with their lab test orders so that PCPs can order these tests for patients (see The Dark Report, July 21, November 3, and October 13, 2014). Those actions show how, at a minimum, the BeaconLBS requirements are already inconveniencing patients because they now must hand-carrying medical laboratory test requisitions from their specialists back to the primary care physicians.
Might 40% of Florida Pathology Groups Be Excluded from Serving UHC Patients?
For anatomic pathologists in Florida, the requirements of the BeaconLBS program have the potential to restrict a large proportion of pathologists from serving the physicians and patients in UnitedHealthcare’s commercial HMO. This potential exists despite the fact that these same pathologists, until now, have met accepted standards of medical practice and have served UHC patients for years.
Both the Florida Society of Pathologists and the College of American Pathologists have complained to UHC about the BeaconLBS program. FSP estimates that about 40% of all pathology practices in the Sunshine State will have trouble meeting the UHC’s requirements in this pilot program (See The Dark Report, January 5, 2015).
Other medical associations have sent letters to UHC explaining their concerns about BeaconLBS, including the Florida Society of Rheumatology, Florida Medical Association, the American Congress of Obstetricians and Gynecologists District XII (Florida), the Florida Academy of Family Physicians, the Coalition of State Rheumatology Organizations, and the American College of Rheumatology.
Despite the fact that this requirement for physicians to obtain pre-notification or pre-authorization for certain medical laboratory tests has raised concerns among Florida physicians about the potential negative consequences for patient care, newspapers (with one exception), and other media outlets in the Sunshine State have yet to write about these developments.
Also, it is known that BeaconLBS representatives are approaching clinical labs and pathology groups in as many as 10 states to sign up these lab organizations and replicate this laboratory benefit management program in those states. In such meetings, it might be enlightening for lab managers and pathologists to ask BeaconLBS to answer the same questions Dr. Kromo and her colleagues in Florida are asking.