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Industry Insights

UnitedHealthcare Pressures Pathology Groups to Participate

Are you familiar with UnitedHealthcare’s Extended Non-Network Reimbursement Program (ENRP)? If you are a pathology group practicing in Texas, Arizona, Florida or Missouri, and you are not participating with UnitedHealthcare, this program applies to you.

Here’s the scenario — a patient goes to an in-network facility, yet receives services from an out-of-network pathology provider.  Under ENRP, UnitedHealthcare will pay based on out-of-network rates. Payment will not be 100% of billed charges, and patients could be balanced-billed the difference.

This “program” was extended into Missouri on January 1, 2015.  A recent article in the St. Louis Post-Dispatch headlined “Patients on the hook for bills” leaves readers concerned about balance-billing and high, out-of-network bills from pathology specialists within in-network facilities.

According to the article, UnitedHealthcare stated it is “deeply concerned that some hospital-based physicians are establishing out-of-network strategies to seek excessively high reimbursement levels, sometimes more than 10 times what an in-network physician would charge for the same service.”

Given this notice from UHC, what will the effects be?  Will your facility pressure your pathology group into participating with UnitedHealthcare to avoid fallout from patient complaints?  What’s your game plan?

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