CMA recently learned that PacifiCare/United Healthcare’s new laboratory policy imposes financial penalties on contracted physicians who refer patients to out-of-network laboratories. CMA this week demanded that state health insurance regulators halt the implementation of this policy, saying it illegally interferes with PPO patients’ right to access out-of-network benefits and improperly obstructs the physician-patient relationship.

The policy, which became effective March 1, authorizes the insurer to fine physicians $50, decrease contracted payment rates, and even terminate the contracts of physicians whose patients choose to go to out-of-network labs. Although PacifiCare United Healthcare (PC/UHC) has advised CMA that physicians will not be penalized without warning, CMA vigorously opposes any health plan attempt to interfere with the physician-patient relationship.

In letters to PC/UHC, the Department of Insurance, and the Department of Managed Health Care, CMA emphasized that PPO policies by their nature include the element of patient choice and as such, physicians must not be penalized when patients exercise their right to select a laboratory of their choice.

“Patients have the right to decide where to receive health care services, without having to worry that their physicians are being fined or otherwise penalized for their choices. This right is particularly acute for patients who pay premiums for nonexclusive PPO benefits,” wrote CMA chief legal counsel Catherine Hanson. “And physicians have the right to speak freely with their patients about their health care choices, without having to worry that they will be fined or otherwise penalized should their patients choose an out-of-network option.”

Physicians should also be aware that effective January 1, LabCorp is PC/UHC’s sole national laboratory services provider. To locate a participating lab in your area, use United Healthcare’s Lab Locator. Physicians may request an exception by calling 877/842-3210.

CMA will continue to work with PC/UHC’s liaison team to resolve this issue.

Contact: CMA’s reimbursement help line, 888/401-5911 or jblack@cmanet.org.